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DISEASES OF THE BREAST 



RODMAN 



DISEASES OF THE BREAST 



WITH 



SPECIAL REFERENCE TO CANCER 



BY 

WILLIAM L. RODMAN, M.D., LL.D. 

PROFESSOR OF SURGERY IN THE MEDICO-CHIRURGICAL COLLEGE OF PHILADELPHIA; PROFESSOR 
OF SURGERY IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA; SURGEON TO THE 
MEDICO-CHIRURGICAL HOSPITAL, THE WOMAn's COLLEGE HOSPITAL, THE PHILA- 
DELPHIA GENERAL HOSPITAL, THE JEWISH HOSPITAL, AND TO THE PRES- 
BYTERIAN hospital; FELLOW OF THE AMERICAN SURGICAL 
ASSOCIATION; membre de la SOCIETE INTERNA- 
l,TIONALE DE CHIRURGIE, ETC. 



WITH 69 PLATES 

OF WHICH 12 ARE PRINTED IN COLORS 
AND 42 OTHER ILLUSTRATIONS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1908 



-^ 






UBHARY of CONaRES! 

Two Copies Recejvd'^ 

FEB 12 H08 

Oovyritfiit tturv 

OLASSA .XXc. rtiu.l 

CO FY k3. 



Copyright, 1908, By P. Blakiston's Son & Co. 



Printed by 

The Maple Press, 

York, Pa. 



DEDICATION. 



TO THE STUDENTS AND ALUMNI 

OF THE 

FOUR MEDICAL SCHOOLS 

IN LOUISVILLE AND PHILADELPHIA 

WHOM IT HAS BEEN MY PRIVILEGE 

AND PLEASURE TO INSTRUCT 

DURING THE PAST TWENTY YEARS 

THIS VOLUME 

IS AFFECTIONATELY INSCRIBED. 



PREFACE 



The advances in the pathology and surgery of mammary affec- 
tions — ^benign and malignant — during the past decade warrant a 
treatise upon the subject at this time. 

Soon after my graduation I saw much of the work of S. W. 
Gross during an interneship in Jefferson Hospital. His earnestness, 
optimism, and successful results early instilled into me a belief as 
to the curability of malignant disease by free and wide removal. 
I have endeavored throughout my practice to follow the teaching 
of this gifted surgeon. He should certainly be looked upon as the 
pioneer in modern breast work in this country. 

My admiration for him as a surgeon and warm personal regard 
for him as a friend caused me to take up this work where he left 
it off. I trust that twenty-five years' work in surgery of the breast 
justify this contribution. 

I desire in the first place to thank and render full acknowledge- 
ment to my friend Dr. Charles W. Bonney, of the Anatomical 
Department of Jefferson Medical College, who wrote the chapters 
on Anatomy and Syphilis, and also materially aided me in review- 
ing the literature, compiling statistics, constructing charts, and 
making dissections. Throughout he has been most obliging and 
helpful to me. 

I am indebted to my friend Prof. Maurice H. Richardson, of 
Harvard University, for many of the beautiful colored drawings 
which so accurately represent the several lesions; also to my friends 
Joseph MacFarland, Professor of Pathology in the Medico-Chirurg- 
ical College; A. O. J. Kelly, Professor of Pathology in the Woman's 
Medical College of Pennsylvania; W. M. Late Coplin, Professor 
of Pathology in the Jefferson Medical College, and Dr. George P. 
Miiller, Demonstrator of Surgical Pathology in the University of 
Pennsylvania, who kindly supplied interesting and rare specimens. 

vii 



viii Preface. 

Doctors MacFarland and Kelly, and their assistants have placed 
me under obligations to them for making microscopical examina- 
tions of tissues removed at the time of and subsequent to operation. 

Dr. Henry S. Wieder, Demonstrator of Surgical Pathology in the 
Medico- Chirurgical College is largely responsible for the chapter 
on Tumors in General and their classification. Dr. George E. 
Pf abler, Medico- Chirurgical College, has kindly supplied many of 
the photographs reproduced, and my clinical assistants, Drs. Stil- 
well C. Burns and Harriet L. Hartley, have rendered valuable as- 
sistance in the preparation, operation, and after treatment of my 
patients. 

The Publishers, P. Blakiston's Son & Co., have been most liberal 
in illustrating the book, and Mr. I. A. Hagy of their staff particu- 
larly has been most obliging, suggestive, and helpful throughout. 

Mr. Charles F. Bauer has placed me under obligations to him 
for the illustrations accurately portraying the several steps of oper- 
ative procedure. 

My secretary. Miss M. G. Cline, has greatly assisted me in read- 
ing proof and in many other ways. 



CONTENTS, 



Anatomy and Physiology 1-26 

Description of the breasts, i; blood-vessels, 5; lymphatics, 10; nerves, 
13; variations from the normal, 14; the male breast, 15; function, 16; 
persistent lactation, 17; development, 17; normal lactation, 18; the 
alveoH during lactation, 22; involution of the breast, 25. 

Inflammatory Diseases 27-42 

Congestion and engorgement, 27; inflammation or mastitis, 28; paren- 
chymatous mastitis, 30; retromammary abscess, 30; treatment of mas- 
titis, 32; chronic mastitis, 35; chronic abscess, 41. 

Tuberculosis 43-56 

Frequency, 43; forms, 43; etiology, 45; pathology, 46; association with 
carcinoma, 48; symptoms, 51; diagnosis, 52; prognosis, 53; treatment, 
54; operation, 54; Wright's bacterial vaccines, 55; Bier's passive hy- 
peremia, 56. 

Syphilis 57-62 

Frequency, 57; modes of infection, 57; forms of mammary chancre, 
58; differential diagnosis of mammary chancre, 58; secondary and ter- 
tiary lesions, 60; differential diagnosis of gummata, 61; diffuse syphil- 
itic inflammation of the breast, 61; method of staining for the spiro- 
chaeta paHida, 62; treatment, 62. 

Actinomycosis 6^ 

Cysts 64-82 

Varieties, 64; single retention cyst, 64; lymphatic cyst, 65; general cys- 
tic disease, 66; galactocele, 74; hydatid cyst, 79; dermoid cyst, 81; se- 
baceous cyst, 82. 

Diffuse Hypertrophy 83-87 

Keloid 88-90 

Tumors in General 91-102 

Nature and origin, 91; Virchow's theory, 91; Cohnheim's theory, 91; 
Senn's theory, 91; Ribbert's classification, 94; clinical varieties, 95; 
characteristics of benign tumors, 95 ; characteristics of malignant tumors, 
96; relative frequency of mammary neoplasms, 99; age incidence of 
benign mammary neoplasms, 100; classification of benign mammary 
neoplasms, loi; classification of malignant mammary neoplasms. 102. 

ix 



X - Contents. 

FiBRO-EPITHELIAL TUMORS IO3-146 

Historical considerations, 103; synonyms, 104; etiology, 106; peri- 
ductal fibroma (fibroadenoma), 106; 'fibro-cystadenoma, 112; papil- 
lary cystadenoma, 114; simple adenoma, 121; prognosis, 122; treat- 
ment, 125; plastic resection of the breast, 126. 

Lipoma 147-149 

Enchondroma 150-152 

Myxoma 153 

Angioma 155-159 

Endothelioaia 160 

Sarcoma 161-172 

Frequency, 161; etiology, 162; pathology, 163; age incidence, 164; 
varieties, 165; myxosarcoma, 165; periductal sarcoma, 166; pure 
sarcoma, 166; symptoms, 166; diagnosis, 169; prognosis, 171; 
treatment, 171. 

Carcinoma 172-371 

Etiology, 173; germ theory, 173; influence of sex, 175; age incidence, 
176; frequency in young women, 177; racial influence, 719; hered- 
ity as an etiological factor, 180; relative frequency in single and 
married women, 181; influence of traumatism and inflammation, 
182; bilateral carcinoma, 183; pathology, 186; varieties of mam- 
mary carcinoma, 186; adenocarcinoma, 186; medullary carcinoma, 
192; carcinoma simplex, 192; scirrhus carcinoma, 195; cancer en 
cuirasse, 195; atrophic or withering cancer, 196; gelatinous or mu- 
coid carcinoma, 199; carcinomatous cyst, 199; the dissemination of 
carcinoma, 200; involvement of the axillary lymph gla'nds, 201; in- 
volvement of the supraclavicular glands, 202; involvement of the 
mediastinal glands, the spinal cord, and the pectoral fascia, 205; 
Handley's theory of permeation, 206; dissemination by the blood 
stream, 211; invasion of the pleura, 214; pulmonary metastases, 214; 
metastases to the bones, 214; metastases in the brain, 217; involve- 
ment of the pelvic organs, 217; symptoms, 217; tendency to conceal 
tumors of the breast, 218; signs of beginning carcinoma, 219; re- 
traction of the nipple, 220; fixation of the breast, 220; enlargement 
of axillary glands, 222; ulceration of the breast, 223; constitutional 
symptoms, 224; progress of atrophic scirrhus, 225; acute cancer, 
226; clinical manifestations of cancer en cuirasse, 230; importance of 
early diagnosis and operation, 235; method of examining a patient, 
241; location of the growth, 242; absence of pain, 245; age in refer- 
ence to diagnosis, 246; value of microscopical diagnosis, 247; injury, 



Contents. xi 

inflammation, and heredity in reference to diagnosis, 248; differen- 
tial diagnosis from fibro-epithelial tumors, 249; from chronic mastitis 
or abnormal involution, 249; from tuberculosis and syphilis, 250; 
from sarcoma, 251; from cysts, 251; prognosis, 253; curability of 
mammary carcinoma, 254; recurrence, 255; operative mortality, 
257; treatment, 259; caustics, 262; trypsin treatment, 263; oophor- 
ectomy, 263 ; history of the operation for the cure of mammary car- 
cinoma, 266; relative importance of the several steps of the operation, 
280; technique, 282; author's method, 287; postoperative treatment, 
319; plastic operations, 322; Warren's operation, 323; Jackson's 
operation, 326; Dawbarn's operation, 361; Tansini's operation, 363; 
palhative operations, 368; treatment of inoperable cases, 370. 

Facet's Disease of the Nipple . . 372-380 

Index 381-385 



DISEASES OF THE BREAST. 



ANATOMY AND PHYSIOLOGY. 

A knowledge of the normal structure and relations of the 
breast is essential for an adequate conception of the mode of 
development, extent and effects of the neoplasms and other 
diseases which affect it, as well as for a thorough understanding 
of the principles upon which their rational surgical treatment 
depends. Therefore a review of the gross and minute anatomy 
of the organ will be given, and the functions so far as they bear 
upon the evolution' of morbid processes afterwards discussed. 

The breasts occupy the anterior and superior aspect of the 
thoracic wall, one lying on either side of the sternum, in front 
of the great pectoral muscles. In shape they are hemispherical, 
although as the result of repeated child-bearing and nursing 
they frequently lose their original contour and the firm, elastic 
consistence with which they are characterized in young women 
who have not borne children, becoming displaced, pendulous 
and flabby. 

At birth the breasts are very rudimentary, and remain so 
until puberty, when they increase rapidly in size. The average 
normal dimensions in the primipara have been given as follows : 
length 4 to 4I inches ; breadth 5 • inches ; thickness 2 inches. 
These figures, however, are by no means constant. It has also 
been observed that the two breasts are rarely of exactly the 
same dimensions. 

The anterior surface is convex, smooth and regular, present- 
ing in its center a dark ring, the areola, which surrounds the 

I 



2 Diseases of the Breast. 

nipple and contains from twelve to twenty sebaceous glands, 
appearing as minute elevations upon the surface. These are 
known as the tubercles of Montgomery. Their arrangement is 
usually irregular. 

Not only does the skin of the areola differ in color from that 
over the rest of the mamma, but it is also characterized by 
absence of subcutaneous fat, and the presence of a layer of 
muscle-fibers beneath it, to which the name of subareolar muscle 
has been given. Most of the fibers are circular, being placed 
around the base of the nipple, but there are also some radiating 
fibers crossing the others in various directions. Contraction 
of this muscle produces erection of the nipple. 

This latter structure is an elevation of variable size and shape 
situated in the center of the areola. It is usually cylindrical 
or conical in form and ends in a somewhat rounded tip contain- 
ing the orifices of the galactophorous ducts. Beneath the 
integument of the nipple transverse and longitudinal muscle- 
fibers are found, constituting the mammillary muscle. The 
former compress the galactophorous ducts and also aid the 
subareolar muscle in protruding the nipple; the latter cause 
retraction of the nipple. 

The posterior surface of the mamma rests upon the great 
pectoral muscle, from which it is separated by the pectoral 
fascia. A layer of cellular tissue intervenes between the apo- 
neurosis of the muscle and the superficial fascia with which the 
gland is intimately connected. 

The glandular substance, with the exception of that portion 
covered by the areola, is completely embedded in fat. The 
subcutaneous layer of fat splits into two portions, one of which 
passes behind the gland, lying between it and the superficial 
fascia, and the other passes in front of it, filling in the depressions 
between the glandular lobes. The anterior layer is very thick, 
the posterior thin. 

The gland itself, when freed from the superficial structures, 



Anatomy and Physiology. 3 

appears as a rough irregular mass of a grayish or light brown 
color consisting of twelve to twenty separate lobes. Elevations 
alternate with depressions. The anterior mass is covered by a 
layer of connective tissue which sends prolongations outward to 
the skin and downward between the lobes of the gland. 

In former descriptions of the breast it was usually stated 
that the glandular substance extended from the second or third 
rib above to the sixth or seventh below, and laterally from the 
outer side of the sternum to near the anterior border of the 



Papilla 



Pyramidal process 



Skin 
Retinaculum cutis 




Sternum 'AvC^ 



Areola 
IKT^'-S:^^ Duct 

\\^^-^^ Retinaculum cutis 

Pyramidal process 
Skm 

Superficial fascia 



- Connective tissue 

Sixth rib 

Intercostals 



Fig. I. — Horizontal diameter of the right mamma. {Morris' " Anatomy. '') 



axilla. It is now known, however, that this description by no 
means always accurately defines the limits of the organ, for it 
has been shown that prolongations of glandular substance may 
extend upwards toward the clavicle, downwards towards the 
external oblique muscle, inwards to the sternum, and outwards 
into the axilla. The last named prolongation is very common, 
and is considered normal by some anatomists. Cusps of gland- 
ular tissue also sometimes perforate the retromammary fascia 
and invade the substance of the pectoralis major muscle. 



4 Diseases of the Breast. 

Each lobe in the gland is provided with its own excretory 
duct, which becomes dilated into a small sac as it approaches 
the nipple. This dilatation is known as the lactiferous sinus. 
As the sinuses advance towards the periphery of the nipple 



Clavicle • 



Pectoralis major . 
Skin 



Retinaculum cutis 
Pyramidal process 




First rib 



Second rib 

Pectoralis minor 
itercostal 
• Pectoral fascia 

Third rib 

Connective tissue 
. Superficial fascia 



Fat 
--' Horizontal plane 



Lactiferous duct 
Lactiferous sinus 



Pyramidal process 

Rectinaculum cutis 



External oblique 

Fig. 2. — Sagittal section of the right mamma of a woman twenty-two years old. 

{Morris, after Testut.) 

they become narrowed again and perforate its tip by means of 
minute openings about 0.5 mm. in width. 

The lobes are made up of lobules, which in turn are composed 
of smaller structures, the alveoli or acini. It is the ducts of these 



Anatomy and Physiology. 5 

alveoli, very minute passages, which unite to form the larger 
galactophorous ducts. The alveoli are lined with cubical epi- 
thelium, as are also the minute ducts leading from them; the 
main excretory ducts, however, are lined with columnar cells. 
Blood Supply. — The mammary gland receives its blood 
from the internal mammary, the external mammary or the long 
thoracic, the superior thoracic, the pectoral branch of the 




Fig. 3. — Arteries of the anterior surface of the breast. First type. 

{Adapted from Piet.) 

a. Secondary artery, b, Principal artery, c. Secondary artery. 

acromio-thoracic, and perforating branches from the aortic 
intercostals, principally the second, third and fourth. 

The principal blood supply comes from the internal mam- 
mary through its first, second, third and fourth perforating 
branches. It has usually been stated that these branches pass 



6 Diseases of the Breast. 

directly to the deep surface of the gland, perforating it and 
sending branches throughout its substance. The recent 
investigations of Piet, however, shqw that such is not the case. 
This anatomist has found that the perforating branches of the 
internal mammary pierce the great pectoral muscle, enter the 
superficial fascia, and then become distributed over the anterior 




Fig. 4. — Arteries of the anterior surface of the breast. Second type. 

{Adapted from Piet.) 

a. Principal artery, b. Secondary artery, c, Secondary artery. 



Stir face of the gland. One branch, which is constant and 
larger than the others, he designates as the principal artery of 
the mamma. There are two distinct types of this vessel, as 
shown in figures 3 and 4. This vessel gives off five or six 
branches of considerable size, as well as a number of smaller 
ones which anastomose with one another to form the plexus 
above mentioned. Some small branches from this plexus are 



Anatomy and Physiology. 7 

transmitted to the interior of the gland, although they do not 
penetrate it deeply. 

The external mammary, or long thoracic, sends a few branches 
around the lower border of the great pectoral muscle just be- 
fore it terminates in the intercostal muscles. One of these 
generally passes to the superficial fascia and anastomoses with 
the vessels of the anterior superficial plexus. 

The superior thoracic sometimes sends a few branches to the 
upper external quadrant of the breast. 



Artery of the nipple 



External branch 




Fig. 5. — Arteries of the areola; posterior aspect. 
{Adapted from Piet.) 

The pectoral branch of the acromio-thoracic, sometimes 
incorrectly called the short thoracic (a term which is liable to 
lead to its confusion with the superior thoracic, the first branch 
of the axillary), sends one or more branches outwards through 
the pectoralis major to the mamma as it pursues its course 
between this muscle and the pfectoralis minor. 

The branches from the intercostals perforate the great pec- 
toral, pass vertically downward between this muscle and the 
posterior surface Of the gland for a distance of two or three 



8 



Diseases of the Breast. 



centimeters, and then perforate the gland to be distributed to its 
deep lobes. Some of them probably anastomose with branches 
from the superficial portion of the gland, although Piet found it 
difficult to inject them through the principal branch of the 
internal mammary. 

From the anterior plexus four or five branches are given off 




Fig. 6. — Veins on the anterior surface of the mammary gland. 
{Adapted from Piet.) 



to supply the nipple and areola. Each of these divides again 
into two branches, an anterior and a posterior, the former of 
which anastomose to form a small subplexus and then pass to 
the extremity of the nipple. The posterior branches are dis- 
tributed beneath the areola. 

The veins correspond in general to the arteries, being super- 



Anatomy and Physiology. 9 

ficial and deep ; the former set are hkewise the most important. 
There is a principal vein corresponding to the principal artery, 
and also not uncommonly a second one of equal size which fol- 
lows the course of the chief lymphatic channel and empties 
into the axillary vein. The principal vein is a tributary of the 
internal mammary. 




Fig. 7. — Veins on the anterior surface of the breast. 
{Adapted from Piet.) 



In addition to these there are five or six smaller veins which 
originate in the subcutaneous plexus and empty into the inter- 
nal and external mammary, the subclavian, and the intercostal 
veins respectively. 

There is an anastomosis of veins around the nipple which is 
known as the circle of Haller. 

The deep veins of the mammary 



gland arc small and few in 



lo Diseases of the Breast. 

number in comparison with those over the superficial portion. 
They anastomose by minute twigs with the superficial veins. 

Thus it is seen that the principal blood supply of the gland, 
both arterial and venous, is superficial. This fact has a 
practical application in the surgery of the gland and will be 
referred to again when the operation of plastic resection of the 
breast for benign growths and cysts is considered. 

Lymphatics. — The mammary gland is drained by a com- 
plex lymphatic system, which is much more intricate and exten- 
sive than it was formerly thought to be. The lymphatic ves- 
sels may be divided into a cutaneous and a glandular group, 
the latter being subdivided into principal and accessory channels. 

The cutaneous vessels may be conveniently considered in 
two groups, namely, those over the periphery and those over 
the center of the gland. The former communicate with the 
vessels of the opposite breast, a fact which may explain the oc- 
currence of infection in the second breast when one is diseased. 
Poirier and Cuneo have recently described a distinct set of ves- 
sels which drains the upper part of the breast and passes directly 
over the clavicle to empty into the supraclavicular glands. 
The central set form an intricate network around the nipple 
and areola which sends branches inward to unite with others 
from the substance of the gland and form the subareolar plexus. 

The principal lymphatic channel, the only one described by 
Sappey, originates in the perilobular sacs, being formed by the 
confluence of minute channels which pass between the galac- 
tophorous ducts towards the nipple and terminate in the sub- 
areolar plexus. From this plexus two trunks are given off, an 
internal and an external, both of which empty into a few glands 
on the internal wall of the axilla, at its upper portion. The ex- 
ternal channel, the smaller of the two, passes directly outwards 
from the breast to the axilla, receiving in its course a tributary 
from the superior portion of the gland. The internal channel 
passes downwards and outwards along the lower border of the 



Anatomy and Physiology. ii 

pectoralis major muscle, which it crosses at about the level of 
the third rib to proceed outward and enter the axilla, where it 
empties into the glands already named. 

In addition to this principal channel, three accessory chan- 
nels are recognized by Poirier and Cuneo. These are the 
internal mammary, the subclavian, and the axillary. The 
internal mammary is formed by the confluence of trunks 
arising from the inner extremity of the mamma; after perfor- 
ating the greater pectoral and internal intercostal muscles it 
empties into the glands of the mammary chain. The subcla- 
vian channel is given off from the posterior surface of the 
mamma, and after perforating the pectoralis major runs be- 
tween this muscle and the pectoralis minor to empty into the 
subclavian glands. There are several small glands along the 
course of this channel which, according to Rotter, are enlarged 
in one-half of all cases of cancer. The accessory axillary 
channel begins at the inferior portion of the gland by a few 
small vessels and passes directly to the axilla. 

Still another accessory channel has been observed by Oelsner. 
This investigator has found several small channels at the 
inferior border of the gland which traverse the great pectoral 
muscle and then pass into the thorax through the fourth inter- 
costal space. Some of these branches follow the intercostal 
vessels to the spine, a circumstance which explains those cases 
of mammary cancer which are ultimately complicated with 
spinal symptoms, or even paraplegia. 

In order thoroughly to understand the possibilities of car- 
cinomatous dissemination through the lymphatic system, it is 
necessary to understand not only the drainage of the mammary 
gland by its principal and accessory large channels, but also to 
possess an adequate conception of the arrangement and dis- 
tribution of the fascial lymphatic plexus. Mr. Handley's 
description of this great lymphatic investment of the body is so 
lucid and concise that I cannot do better than quote it. 



12 



Diseases of the Breast. 



''This great plexus is divisible by the median plane of the 
body and by two horizontal planes passing through the clavicle 
and through the umbilicus respectively, into six catchment 
areas, three on either side, draining as the case may be into 
the cervical, the axillary, or the inguinal glands. The line, 
or rather zone, separating any two adjacent areas, may be called 
the lymphatic water-parting, and is anatomically a zone of nar- 




Fig. 8. — Lymphatic vessels of the anterior surface of the breast; the subareolar 
plexus and the trunks which run from it (Sappey). i, i. Lymphatic network of 
the anterior surface of the mammary gland. 2, 2. Lobules of the gland, the 
peripheral network of which has not been injected in order that the circumlob- 
ular network which encircles it may be seen. 3, 3, 3, 3. Trunks which arise 
from the upper and lower parts of the gland. 4, 4. Subareolar lymphatic plexus. 
5. Lymphatic vessel which arises from the inner part of this plexus. 6. Vessel 
arising from the inner part of the same plexus. 7. Vessel coming from the lower 
part of the gland; after a long course it unites with the preceding to form one of 
two trunks in which all the others end. 8, 8. The two principal lymphatic trunks 
which extend transversely from the mamma to the axillary glands. {"The 
Lymphatics," C. H. Leaf.) 

row tortuous channels, nowhere traversed by trunk lymphatics, 
a region, consequently, where the lymph stream is at its feeblest, 
and where even very fine particles are liable to be arrested. 

"The general idea then, which we have obtained of the pari- 
etal lymphatic system is that of a vast horizontal network of 
fine channels, co-extensive with the surface of the body, and re- 



Anatomy and Physiology. 13 

ceiving above numberless fine vertical tributaries, which con- 
vey to it the lymph from the skin and its appendages. Among 
the latter we must include the breast. On its deep aspect the 
plexus receives tributaries from the subjacent tissues. From 




Fig. 9. — Lymphatic vessels of the antero-lateral portions of the thorax 
(Sappey). i, i. Axillary glands. 2, 2. Superficial lymphatic trunks of the 
upper limb. 3, 3. Large trunks which also come from the integuments of the 
upper limb, but which instead of ending in the glands of the axilla, run in the 
space between the deltoid and pectoralis major, and terminate in a subclavicu- 
lar gland. 4. A gland which is sometimes seen in the course of this trunk. 
5, 5. Lymphatic vessels of the anterior superior part of the thorax.. 6, 6, 7, 7. 
Lymphatic vessels which start from the integuments of the thorax. {"'The 
Lymphatics,^' C. H. Leaf.) 

this great plexus, which lies in the subcutaneous fat upon the 
deep fascia, the lymph is conveyed by six sets of lymphatic 
trunks,* each draining a definite area, to the cervical, the 
axillary, or the inguinal glands." 

Nerves. — The nerves of the mammary gland are derived 



14 Diseases of the Breast. 

from the intercostals, from the supraclavicular branch of the 
cervical plexus, and from thoracic branches of the brachial 
plexus. They are distributed to the skin over the gland, to the 
muscular fibers of the areola, to the blood-vessels, and to the 
glandular substance itself. 

Variations from the Normal. — There may be either a re- 
duction or an augmentation in the number of the breasts. To 
the former condition the term amazia is applied, to the latter, 
polymastia. 

Congenital absence of both breasts is exceedingly rare, and 
unilateral absence is by no means common. 

Absence of the nipple is another abnormahty which requires 
mention. To this condition the term athelia is applied. When 
it exists the galactophorous ducts make their exit at the center 
of the areola, usually in a slight depression occupying the site 
of the nipple. 

Increase in the number of breasts, or polymastia, is much 
more common than amazia. Polythelia, or the presence of 
more than one nipple, is also comparatively frequent. The 
supernumerary nipple may be situated on the areola, close to 
the normal nipple, or it may be located some distance away 
from this part of the breast. 

In regard to the supernumerary breasts, their size and loca- 
tion is most variable. It is interesting to note, however, that 
they are most commonly found on those portions of the body 
where breasts normally occur in certain animals. Thus they 
are often found in the axilla or upon the borders above or below 
the normal breast, on the lower portion of the thoracic wall, 
and also on the abdominal wall. Their occurrence on the 
abdomen, however, is much rarer than on the portion of the 
body previously named. 

They have also been found on the back, the shoulders, and 
various parts of the thigh. 

As regards their numerical occurrence, not more than one or 



Anatomy and Physiology. 15 

two are present, as a rule, although three sometimes occur, and 
there are isolated cases on record in which six or eight have 
been present. In most cases probably there is only one. 
Polymastia occurs in men as well as women, and by some 
anatomists has been considered equally as common among 
them as among the latter sex. Recent statistics, however, 
show that it is more frequent among women. Of two hundred 



Fig. 10. — Lymphatics of the breast and axillary glands (semidiagrammatic). 
I. Delto-pectoral gland. 2, 2. Glands of the humeral chain. 3, 3. Glands of 
the central group and the scapular chain. 4, 4. Glands of the thoracic chain 
(supero-internal group). 5. Gland of the thoracic chain (infero-external group). 
6. Subclavian glands. 7. Mammary lymphatic ending in the subclavian glands 
(inconstant). 8, 9. Mammary collecting trunks, ending in glands of the thoracic 
chain. 10. Subareolar plexus. 11. Cutaneous collecting trunk of the lateral 
walls of the thorax. 12, 13. Mammary collecting trunks about to end in the in- 
ternal mammary glands. (" The Lymphatics," C. H. Leaf.) 

and sixty-two cases collected by Hanseman only a small per- 
centage were in men. 

Heredity is supposed to play a role in its occurrence. These 
breasts are seldom functionally perfect. 

The Male Breast. — In the adult male the mammary gland 
is perfectly developed. At birth, however, it is of about the 
same dimensions as in the female. At puberty signs of evolution 
sometimes appear, the gland enlarging somewhat and becoming 



i6 



Diseases of the Breast. 



slightly painful. These signs of activity soon subside and the 
gland returns to its original size. 

Its structure is practically the same as that of the female 
organ with the exception that a typical areola is not found. 
The galactophorous ducts are also rudimentary. 

Physiologically the breast is a secreting organ appurtenant 
to the reproductive system, and characterized particularly 




Fig. II. — Scheme of the axillary glands. 2. Supraclavicular glands, b. Sub- 
clavian glands, c. Humeral chain, d. Scapular chain, e. Infero-external 
portion of the thoracic chain. /. Supero-internal portion of the thoracic chain. 
g. Central group. The dark dotted line indicates the situation of the clvicale. 
(" The Lymphatics,'' C. H. Leaf.) 

by periodical phases of activity, which are most pronounced 
during the era of active sexual life. 

The secreting power of the gland, however, often manifests 
itself shortly after birth, inasmuch as a small quantity of milk 
is discharged from the nipple. 

That this secretion is a true lactation has been proved by 
De Sinety (Arch, de Physiologic, 1875) ^^^ ^^^o by Variot, 
KoUiker, Barfurth and others. 

This activity soon subsides, as a rule, and the gland remains 
quiescent until puberty, when its dormant vitality is first 



Anatomy and Physiology. 17 

markedly aroused and it undergoes a series of changes in com- 
mon with the other organs constituting the reproductive 
system. 

A few cases of persistent lactation in the new-born have 
been recorded. Thus Mr. Sheild mentions one occurring in a 
female child aged sixteen days. A more remarkable case is 
one recently reported by Mr. Murray (Lancet, Jan. 7, 1905) 
occurring in a male child aged three and one-half months. 
Both breasts, which were enlarged to about the size of a billiard 
ball, were firm with palpable gland substance ; the nipples were 
also enlarged and oozed fluid resembling milk. The mother 
said the child's breasts began to enlarge when he was five 
weeks old, and had gradually increased in size. The child 
died from congenital heart disease three weeks after admission 
to the Hospital. Section showed both breasts to be lactating. 
The gland substance was healthy, the ducts enlarged and irregu- 
lar. Microscopically the secretion resembled milk, although 
the fat content appeared low. 

At puberty there is a rapid growth of the organ, which soon 
attains the normal size, form and consistence that characterizes 
it in the adult female who has never borne children. It does 
not reach its highest degree of development until pregnancy, 
parturition and lactation have taken place. Thus, although 
the increase in the size of the breast occurring at puberty is 
accompanied by formation and partial development of alveoli, 
which are the physiological units of the organ, these structures 
are not completely developed until the first pregnancy has 
terminated and lactation begun. At puberty they develop 
only at the periphery of the gland. 

The structural transformation which the breast undergoes 
at puberty is accompanied by manifestations of functional 
awakening ; and just here it may not be amiss to state that struc- 
ture and function are inseparably connected, that when the 
potential specific activity existing in the organ from the estab- 



i8 Diseases of the Breast. 

lishment of puberty to the incidence of the chmacteric becomes 
actually manifest, certain alterations in the structure of the 
alveoli, the physiological units, are observed to take place. 
These are particularly marked during the period of lactation, 
and will be described in detail when this subject is discussed. 

In reference to the functional manifestations which occur 
at puberty, it has been observed that pain is frequently com- 
plained of, that the breasts are tender to touch, and that slight 
swelling of the lymphatic glands which receive the lymph from 
the mamma sometimes occurs. 

After the establishment of puberty the gland becomes quies- 
cent until pregnancy occurs, when it undergoes decided changes. 
At about the eighth week after conception the breasts begin to 
increase in size and continue to enlarge until the termination 
of pregnancy, and for some days thereafter. There is an increase 
in all the constituent structures. The alveoli become larger 
and more numerous, the blood-vessels distended, the superfi- 
cial veins prominent, the areola larger and darker in color, and 
the nipples swollen and sore. The secondary areola is also 
formed at this time. The tubercles of Montgomery enlarge, 
and striae form in the skin owing to the pressure exerted upon 
it by the distended gland. 

If the alveoli be examined microscopically at this period, 
it will be found that they are in reality solid cylinders composed 
of cells. Toward the close of pregnancy, or soon after delivery, 
some of these cells are cast off, leaving a single mosaic layer 
to line the walls of the alveoli. 

All these changes are wrought in anticipation of and prep- 
aration for the specific function of lactation, which begins 
shortly after the occurrence of parturition. 

For the first day or two after delivery the breasts secrete a 
substance known as colostrum, a yellowish- white fluid contain- 
ing cast off cells which have undergone fatty degeneration and 
which are known as colostrum corpuscles. It is supposed 



PLATE I. 




Section from a non-lactatiiig breast. 



Anatomy and Physiology. 21 

that these cells are derived from the interior of the alveoli, that 
they do not possess the secreting power peculiar to those which 
line the alveolar walls and that they are therefore cast off. The 
destruction of these cells creates a lumen within the alveoli 
which was not present during pregnancy. Thus receptacles 
are formed for the milk before it begins to be secreted. 

The fluid portion of the colostrum is merely a serous trans- 
udate and in no wise a specific secretion of the mammary gland. 

Usually on the second or third day after delivery milk begins 
to be secreted. Its appearance is not uncommonly accompanied 
by slight local and constitutional disturbances, which are the 
expression of the increased cellular metabolism upon which 
the production of the milk depends. Thus slight elevation 
of temperature, as well as soreness and swelling of the 
breasts, sometimes occurs. Enlargement of the lymphatic 
glands in the axilla and above the clavicle has also been known 
to take place. These changes are due entirely to increased 
functional activity of the gland, and not to any extraneous 
causes. Perhaps it may be absorption of waste-products of 
the cells, products which are elaborated and cast off as the 
result of the increased work going on in the gland, that produces 
these phenomena. 

That the secretion of milk is governed by the nervous system is 
shown by experimentation and clinical observation. Although 
the results of the former are not entirely in accord, enough 
has been demonstrated to show that there is a decided nervous 
influence presiding over the function of lactation. Stimula- 
tion of the mammary nerve in a bitch was followed by secretion 
of milk (Laffont). Irritation of the sensory nerves in the nip- 
ple also results in a more profuse flow of milk. Thus it is 
weU-known among parturient women that putting the child to 
the breast stimulates the secretory power of the gland. Remark- 
able cases have been reported in which the male breast was 
stimulated to secretion in this manner. 



22 Diseases of the Breast. 

The influence of fright and anxiety is well-known ; it is not at 
all unusual for complete temporary arrest of secretion to occur 
in women who are subject to either of these emotions. 

We have already seen that the mammary gland develops 
simultaneously with the organs properly constituting the repro- 
ductive system. Its intimate relation with these organs is 
again manifested not only during pregnancy, when it attains 
a high degree of development, but also during the period of lac- 
tation. Thus it has been observed that the uterus sometimes 
fails to undergo normal involution when milk fails to be secreted, 
a circumstance which may be attributed to the absence of 
uterine contractions produced by the stimulation of suckling. 

If now we come to study the alveoli, the functionating por- 
tion of the breast, during the period of lactation, not only will 
their condition be found different than it is before and during 
pregnancy, but variations will be observed according as they 
are examined when actively functionating or at rest. To these 
conditions Michael Foster has applied the terms loaded phase 
and discharged phase respectively. He describes them as 
follows : 

"In the discharged phase the alveolus is lined by a layer of 
low cubical or even flattened cells, so that the relatively large 
area of the alveolus is almost wholly occupied by the lumen 
in which some of the constituents of the milk may still be 
retained. Each cell consists of granular cell-substance in 
which is placed a rounded or oval nucleus; sometimes the free 
edge of the cell is jagged and uneven as if a portion of the bor- 
der had been torn away. 

"In a fully loaded phase the appearances are very different. 
The alveolus is now lined with a layer of tall columnar cells 
projecting unevenly into the lumen, the outline of which 
is correspondingly irregular and the area of which is much 
reduced. While the broader base of each cell rests on the base- 
ment membrane, the other end, the conical or irregular, stretches 



PLATE 11. 




Section from a lactating breast. 



Anatomy and Physiology. 25 

towards the center of the lumen. Instead of one nucleus two 
or more are now present, one, well-formed and normal, being 
placed near the base, and the others, often showing signs of 
breaking up or degeneration, nearer the free end. Some of 
the cell, including one or more of the nuclei, is apparently 
being separated from the basal portion in which the remaining 
nucleus is lodged, and occasionally portions or fragments of 
cells, nucleated or nucleusless, may be seen lying in the cavity 
of the alveolus. In the cell-substance, especially toward the 
free border of the cell, are numerous oil-globules of various 
sizes, as well as granules or particles of other nature; some 
of the larger oil-globules may be seen projecting from the 
surface as if about to be extruded from the cell; and in the 
cavity of the alveolus oil-globules with a thinner or thicker 
coating of cell-substance are frequently present. 

^'Between such a fully loaded phase, and a completely dis- 
charged phase, various intermediate conditions may be observed, 
the cells being of greater or less height, containing one nu- 
cleus only or more than one, the cell-substance occupied with 
few or many oil-globules and other granules, and the free border 
more or less jagged." 

This detailed description of the physiological unit of the 
mamma during the stage of its greatest activity has been quoted 
in order better to contrast the condition which obtains in it 
during the subsidence of lactation and the period in which it 
is restored to its previous condition. The microscopic appear- 
ance of the non-lactating and lactating breast is shown in Plates 
I and II respectively. 

The term involution is applied to the process by which the 
breast is rehabilitated. 

If a section of the .mamma be examined during the period of 
involution, the alveoli will be found to be much smaller than 
they were during lactation. The cells lining their walls are 
much reduced in number and are also smaller in size, and their 



26 Diseases of the Breast. 

protoplasm has disappeared, leaving the nuclei unsurrounded. 
As the process of involution progresses the alveoli become con- 
verted into spherical spaces containing the nuclei of the cells 
which lined their walls during the period of lactation. These 
contracted alveoli are not surrounded by minute blood-vessels 
as they are when the gland is at the height of its activity, al- 
though some are still seen ramifying in various directions. 

The contraction of the alveoli is uniform throughout the 
lobule, as a result of which the various lobules become reduced 
in size, spaces being formed between them. 

In addition to the alterations in the alveoli, changes also 
occur in the other portions of the gland. Thus there is an 
increase in the fibrous tissue between the lobules and in the fat 
surrounding the gland. 

When another pregnancy occurs the same process of evolu- 
tion previously described is gone through and the functionating 
power of the gland again raised to its highest degree during the 
ensuing period of lactation. 

It is evident that these phases of evolution and involution 
of the breast are accompanied by much tissue formation and 
tissue destruction, and it is not unreasonable to suppose that 
deviations from the normal method of metamorphosis furnish 
a basis for the development of some of the morbid processes 
to which the organ is subject. Reference to this matter will 
be made again when considering the pathology of tumors. 

During the climacteric the mammary gland atrophies and 
becomes much decreased in size. 



INFLAMMATORY DISEASES OF THE BREAST. 

Under this heading will be considered congestion and en- 
gorgement, acute mastitis, acute abscess, chronic mastitis, and 
chronic abscess. 

With the exception of chronic mastitis these affections are 
most common in the puerperium, and, indeed, engorgement of 
the milk-ducts occurs at no other time. 

The terms congestion and engorgement are commonly ap- 
plied to the same condition, namely, distention of the galactoph- 
orous ducts with milk. The inflammation or congestion of 
the breast occurring in the new-born and at puberty has already 
been mentioned. In the former it is more hkely to develop 
if attempts are made to press the secretion out through the 
nipple. 

If infection takes place, as not uncommonly happens, sup- 
puration may ensue. 

Usually these affections are readily relieved by simple hot 
applications. Sometimes, however, suppuration ensues and 
then incision is required. The subsequent cicatrization may 
interfere with the development of the breast. The pressure 
resulting from distention of the breast with milk gives rise to 
irritation and swelling of the affected parts, which most com- 
monly are the lower and external portions. 

These local manifestations of interference with the normal 
function of lactation are accompanied by signs of constitutional 
disturbance which, however, are slight unless an infective process 
be superimposed upon the one already present. Thus a slight 
rise of temperature and moderate headache, together with a 
general feeling of ill-being, are not infrequently present. 

It has been observed that the incidence of this affection is 

27 



28 Diseases of the Breast. 

most common on the third or fourth day after delivery. It 
may occur at any time, however, particularly if nursing be sud- 
denly interrupted, as for example, by the death of the child, 
or because of soreness of the nipple so severe as to prevent 
suckling. 

The therapeutic indications are to empty the breasts, relieve 
congestion, and afford proper support. 

They are met by gentle massage, properly supporting ban- 
dages, hot moist applications, and the administration of saline 
cathartics. 

The breast may be gently rubbed with warm sterilized olive- 
oil, or with a mixture composed of lanoline one part and ben- 
zoated lard seven parts, the mixture being liquefied and steril- 
ized in a water-bath each time it is used. The use of a fatty 
substance in conjunction with massage seems to be of real 
benefit as well as being decidedly grateful to the patient. 

Hot moist applications may be used in the intervals. A 
flannel wrung out of hot normal saline solution or a saturated 
solution of boric acid may be applied to the breast and covered 
with oiled silk, being changed as soon as it begins to get cold. 
Such applications may be kept up constantly if a nurse is in 
attendance, otherwise they are to be made for periods for one- 
half hour, three or four times a day. 

As already stated properly supporting bandages are to be 
applied. As the engorgement subsides compression may be 
increased by putting cotton or wool beneath the bandage and 
binding it firmly to the skin. 

In regard to the purgatives Epsom or Rochelle salts answer 
every purpose. 

It was formerly held that engorgement of the breast was the 
cause of mastitis and abscess. It is now known, however, that 
such is not the case, although it is still admitted that engorge- 
ment acts as a predisposing cause. 

The essential cause of inflammation of the breast, whether 



Inflammatory Diseases of the Breast. 29 

simple or suppurative, is infection with microorganisms, prin- 
cipally the staphylococcus pyogenes aureus. Streptococcic 
infection may also occur, and is of a particularly virulent form, 
giving rise to suppuration and severe constitutional disturb- 
ances. 

Infection usually, though not always, takes place through an 
abrasion on the nipple, areola, or skin on some other portion of 
the breast. 

It is theoretically possible, and no doubt sometimes actually 
happens, that germs already present in the gland are aroused 
to renewed activity during the period of lactation, with the re- 
sult that inflammatory processes are lighted up. It is evident 
that the congestion incident to engorgement of the gland would 
afford a favorable soil for the growth of any organisms pres- 
ent, for example, those left dormant after the subsidence of a 
previous attack of suppurative inflammation. 

The occurrence of mammary abscesses during the course of 
pyemia or as a complication or sequel of erysipelas furnishes a 
good example of infection by way of the blood current. 

In the vast majority of instances, however, careful examina- 
tion will reveal a solution of continuity in some part of the in- 
tegument, usually on that covering the nipple or areola. 

The infection may be conveyed through the mouth of the 
child, by the hands of a dirty nurse or a careless physician, 
or by the mother herself. 

Three varieties of inflammation are distinguished, namely, 
superficial or subcutaneous, deep or parenchymatous, and 
retromammary. 

In the superficial form the infective microorganisms are 
conveyed by the lymphatics to the tissues just beneath the 
areola, or occasionally for a short distance beyond, where they 
set up an inflammatory process. The affected area becomes 
reddened, sore, and swollen. 

The inflammation is prone to extend superficially, especially 



30 Diseases of the Breast. 

if it goes on to suppuration, advancing towards the skin rather 
than laterally. This circumstance is due to the fact that lat- 
eral extension is limited by the superficial processes of fibrous 
tissue extending from the interlobular septa to the skin. 

It may, however, invade the deeper portions of the gland, 
extending along the interlobular septa and thus giving rise to 
the parenchymatous form. The septa between contiguous 




Fig. 12. — Acute mastitis. 

lobules may be broken down and the breast become honey- 
combed, or the pus may extend along an interlobular septum 
to the tissues behind the gland and lead to the formation of a 
retromammary abscess. In the latter instance a considerable 
accumulation of pus may result, so that the breast becomes 
elevated and pushed forward from the thoracic wall. The 
pus may even work its way into the axilla, extending along the 



Inflammatory Diseases of the Breast. 31 

anterior border of the pectorahs major muscle and perforating 
the dense fascia forming the floor of this space. There is almost 
always enlargement of the axillary glands even though the sup- 
purative process itself does not invade the axilla. Difhculty 
in moving the arm is also experienced. The pain, which is 
most severe, is deep seated, owing to the location of the morbid 
process; it also gains some of its intensity no doubt from the 
resistance to its extension offered by the surrounding structures. 

Thus the absorption of pus is increased, with the result that 
the manifestations of sepsis are intensified. 

Finally, in this form of the disease, it is noteworthy that the 
skin over the anterior surface of the breast is not reddened as 
it is in the superficial and parenchymatous forms. 

These retromammary abscesses are not very common. 

In regard to the symptoms and signs of mastitis, it has already 
been stated that superficial infection produces redness, swelling 
and soreness of the affected parts. There is, moreover, slight 
constitutional disturbance. 

If the morbid process is not arrested in this stage, but ad- 
vances to suppuration, both local and constitutional phenomena 
become greatly intensified. The swelling of the breast in- 
creases, great discoloration of the part takes place, and as 
destruction of tissue goes on and one or more areas of fluctuation 
form, violent throbbing pain, chills and fever, and a greater or 
less degree of prostration are experienced. The pulse becomes 
accelerated, the tongue coated, and the skin hot and dry. 
Profuse sweats sometimes break out. In a word, the clinical 
picture is one of septic infection, presenting different degrees 
of intensity in accordance with the virulence of the infecting 
microorganisms and the extent of the destructive process which 
they produce. 

Streptococcic infection is most severe, causing all the symp- 
toms and signs of acute sepsis. 

The diagnosis is not difficult as a rule, although in the early 



32 Diseases of the Breast. 

stages of parenchymatous mastitis it is difhcult or even may be 
impossible to determine whether pus has formed. As the 
process advances, however, all doubt will be dispelled. Both 
the local and constitutional manifestations above mentioned 
will become so pronounced as to make the nature of the trouble 
clear. Fluctuation is the crucial test. 

In superficial abscess or suppuration of the glands of Mont- 
gomery the diagnosis is readily made. 

Retromammary abscess will be recognized by the symptoms 
and signs already enumerated. 

Treatment. — The treatment varies according as the case 
is seen before or after suppuration has occurred. 

Prophylaxis is of the utmost importance, and will be discussed 
before treatment is considered. 

If scrupulous cleanliness of the nipple and breast is observed 
before and especially during lactation, if measures be taken to 
prevent the formation of fissures of the nipple, and prompt 
and careful treatment given to any which may form despite 
the precautions employed, the occurrence of mastitis and mam- 
mary abscess can be much diminished. 

During pregnancy small retracted nipples should be regularly 
drawn out, although great gentleness must be employed in this 
manipulation, as otherwise injury may be inflicted and thus the 
very danger we are trying to obviate be increased. 

Any abrasions or fissures which may be detected should be 
promptly treated by healing or slightly astringent applications, 
such as boric acid ointment or weak glycerite of tannin. 

After labor it is well to wash the breasts and nipples with 
castile soap and warm sterilized water, and then apply a satur- 
ated solution of boric acid. The use of bichloride of mercury 
solution does not seem necessary to me, although it has been 
recommended by many competent obstetricians. 

A proper supporting bandage should also be applied to the 
breasts for the purpose of preventing engorgement. 



Inflammatory Diseases of the Breast. 33 

Each time before the child is put to the breast its mouth 
should be gently washed with the saturated solution of boric 
acid, and the nipple should be cleansed with the same solu- 
tion both before and after nursing. If the nipple becomes 
sore despite these precautions, a shield should be used and the 
antiseptic wash continued. Oftentimes an ointment composed 
of boric acid, 15 grains; lanoline, two drams; and benzoated 
lard, six drams, will heal abrasions and beginning fissures. The 
breast-pump must be used if nursing is so painful as to be intol- 
erable. 

The treatment of mastitis itself consists in the application 
of evaporating solutions, such as lead-water and laudanum or 
a two percent solution aluminum acetate; the maintenance of 
proper support; free purgation with saline cathartics, and the 
discontinuation of nursing. Ice applied to the inflamed parts 
is often of benefit, but patients very commonly complain of its 
being painful. The breast-pump is to be used when nursing 
is stopped. If these measures do not succeed in arresting 
the inflammation, and particularly if the process be severe, it 
is good surgery to make a free incision into the affected parts, 
even before pus can be detected. This will often obviate the 
formation of abscesses. 

In regard to the treatment of suppurative disease, whether 
superficial or deep, free incision and drainage is of course the 
only measure to be considered. All abscesses are to be opened 
at once. 

. The incision or incisions should radiate from the nipple so 
as not to divide the galactophorous ducts. In superficial 
abscesses it will suffice to effect a free opening and provide drain- 
age after the contents are evacuated. In deep abscesses where 
much destruction of tissue has occurred it often becomes 
necessary to make counter-openings and institute through and 
through drainage by means of rubber tubes. Cases in which 
the purulent collections have been evacuated spontaneously, 



34 Diseases of the Breast. 

with the result that sinuses have been left behind, require care- 
ful and most thorough attention. Free incisions must be made, 
the walls of the sinuses scraped, and the partly closed abscess 
cavities likewise curetted. In such cases it is well to irrigate 
with bichloride of mercury solution 1-4000. Drainage is 
also to be practised. 

In retromammary abscess the breast is to be lifted up and a 
free opening made at the mammary- thoracic fold. If there is 
suppuration in the axilla, a free opening must be made and 
the space drained. In these cases it may become necessary to 
turn the breast up as in the operation of plastic resection of 
benign growths and lay abscess cavities freely open, thoroughly 
breaking down any septa or remains of septa which may be 
present between the different parts. 

In suppuration the danger consists not in doing too much, 
but in doing too little. Early and free opening of the affected 
parts will invariably give satisfactory results, whereas delay, 
procrastination, and loathness to use the scalpel freely when it 
is employed will be followed by extensive destruction of tissue. 
It is especially in the neglected cases that extensive procedures 
are demanded, and it is certainly true that timely interference 
would almost invariably have been conservative of the mammary 
tissues and, moreover, have saved the patient much suffering. 

After the breast has been opened it must always be supported 
by a suitable bandage in addition to the usual surgical dressings. 
It is well to bandage the arm to the side. 

The drainage tubes are withdrawn gradually as healing 
takes place. For cleansing the wounds probably nothing is 
better than hot normal saline solution, although in cases of 
virulent infection, one or two irrigations with weak bichloride 
(1-5000) may be employed. As the wounds begin to grow 
healthy the formation of granulation tissue may be stimulated 
by balsam of Peru. Tonics and a generous diet should be 
given to maintain the patient's strength. 



Inflammatory Diseases of the Breast. 35 

The treatment of abscess comphcated with sinuses has 
already been alluded to. In obstinate cases, in which the breast 
has been so riddled that very little healthy tissue remains, it 
has been necessary to perform amputation. This is a very 
radical procedure and should be employed only as a last resort. 

If there be only one or two sinuses which have persisted, 
the excision of a wedge-shaped piece of tissue surrounding the 
sinus, after the method practised by A. Marmaduke Sheild, 
will often effect a cure. 

The treatment of suppurating hematoma differs in no wise 
from that of simple abscess. Cure is rapid after evacuation 
of the pus, blood and clot. 

Chronic Mastitis. 

The term chronic mastitis, as understood here, is applied 
to a chronic inflammatory process affecting the mammary gland 
and characterized by the formation of fibrous tissue, which 
results in compression of the acini and ducts, thus leading to 
atrophy, and sometimes to obliteration of these structures. 
Another change which not uncommonly occurs is cyst-forma- 
tion in the ducts, due to the occlusion of a certain portion of 
their lumen and consequent dilatation of the remaining portion. 

It is also certain that changes in the epithelium take place 
in a certain number of cases, according to Warren in about 
one-half. 

The process may be localized or diffuse. 

In regard to the etiology of this affection, it is positively 
known that acute inflammation and abscess may be followed 
by the formation of fibrous tissues and cicatricial contraction. 
Cases of acute mastitis in which the inflammatory process did 
not advance to suppuration frequently fail to undergo complete 
resolution, areas of induration persisting indefinitely, or some- 
times undergoing gradual involution until they finally disappear. 
So, too, there is a formation of fibrous connective tissue to re- 



36 Diseases of the Breast. 

place the destruction of normal mammary tissue incident to sup- 
purative disease. In like manner injury may also give rise to 
the same tissue changes, blows and bruises setting up conges- 
tive and inflammatory processes which are followed by the 
formation of new tissue and a certain degree of contraction, 
whereas open wounds result in more pronounced though similar 
changes as healing occurs. 

Chronic inflammation of the breast developing as the result 
of any of these causes is not at all difficult to understand, 
inasmuch as it represents the usual sequel of acute inflam- 
mation and suppuration. Quite different, however, are those 
cases in which there are no distinct antecedent etiological factors 
such as have been enumerated above. 

First of all it is necessary to admit that we are not in posses- 
sion of complete knowledge in regard to the formation of fibrous 
tissue in the various organs of the body. Thus, for example, 
the exact manner of development of chronic contracting kidney 
and cirrhosis of the liver is not absolutely clear; the same is 
true of the formation of those tumors containing much fibrous 
tissue. 

As regards certain cases of the affection under consideration 
even less is known than concerning the conditions above cited. 
x\lthough comparatively little has been ^Titten relative to a class 
of cases to which Franz Konig applied the term diffuse intersti- 
tial mastitis, the most varied opinions have been expressed about 
its causes, nature, and mode of development. A similar diver- 
sity of opinion has prevailed in regard to the localized form of 
the disease occurring irrespective of any well-defined causes. 
Reference to these matters will be made again. 

It is well-known to aU surgeons who have had much experi- 
ence with diseases of the mammary gland, that it is not unusual 
for women of different ages, but particularly those who are 
near the menopause, to present themselves with the statement, 
that they have either discovered one or more hard and perhaps 



Inflammatory Diseases of the Breast. 37 

tender areas in their breast, or that the entire breast has become 
swollen, indurated, and more or less painful. Careful inquiry 
fails to elicit any adequate cause for the supervention of such 
a condition. There may or may not be a history of preg- 
nancy and lactation or a recollection of previous injury to the 
breast. 

As regards the relative frequency of these conditions in the 
married and unmarried, I am of the opinion that it is rather 
more common in the former class, and I believe that this view 
is sustained by the experience of other observers. 

Upon what can these conditions depend? What are the 
factors leading to the production of tissue metamorphosis ? 

In answer to these questions I will state that I believe the 
structural changes are associated with and represent variations 
from the normal function of the gland. When considering 
the physiology of the breast attention was directed to the 
destruction and reproduction of tissue incident to lactation, and 
also to the intimate relation existing between the mammary 
gland and the reproductive organs. Moreover, it was stated 
that function and structure are inseparable, that variations 
of the former depend upon alterations in the latter. 

Irrespective of the acute diseases to which the breast is sub- 
jected during lactation, certain conditions which may obtain in 
it during the periods of involution and evolution, particularly 
if they be frequently repeated, seem to me to be especially 
conducive to the development of the affection under considera- 
tion. Thus, failure of complete rehabilitation throughout the 
entire gland may very likely lead to an undue proliferation of 
cells resulting in the production of connective tissue It is 
not improbable that the effect of rapidly repeated pregnancies, 
necessitating evolutionary changes in the gland before a period 
of repose can be had after its recent involution, might act as a 
stimulus to aberrations of tissue formation. 

These views, although largely speculative, seem to be worthy 



38 Diseases of the Breast. 

of consideration, as they are based upon well-estabhshed prin- 
ciples of physiology and pathology. 

In regard to those cases occurring in women who have never 
been pregnant nor borne children, it may be assumed that the 
very deprivation of normal function to which the gland has 
been subjected may have stimulated the glandular structures 
to compensatory though abortive efforts to functionate, with the 
result that tissue changes are set up which lead to the same 
alterations in structure as have been supposed to be produced 
by the excessive stimulation incident to frequently occurring 
periods of involution and evolution. 

Another factor to which I believe not enough importance 
has been attached, and one to which, so far as I am aware, no 
writers have called attention, is the interruption of pregnancy, 
with the consequent sudden arrest of evolutionary changes in the 
breast and the establishment of involutionary changes before the 
period of evolution and lactation has been completed. It seems 
probable that such a departure from the normal cycle of changes 
through which the mammary tissues pass during pregnancy and 
lactation might well give rise to disturbances of their rehabilita- 
tion, or lead to an abnormal proliferation of cells capable of 
giving rise to this morbid process. I have seen women who 
aborted during the fourth and fifth months of pregnancy suffer 
considerably with swelling and soreness of the breast. This 
is certainly indicative of disturbed function. 

Many cases of abortion, particularly those which are crimin- 
ally induced in illegitimate pregnancies, are scrupulously con- 
cealed, so that no history whatsoever can be obtained. Under 
such circumstances the most that can be done is to infer the pre- 
vious existence and interruption of pregnancy, if the general as- 
pect of the breasts lead one to suspect that it has occurred. 
This, however, is not of great help, as the majority of abortions 
are induced before pregnancy has advanced far enough to leave 
its permanent signs upon the breasts. 



Inflammatory Diseases of the Breast. 39 

It is questionable whether some cases in which diffuse 
chronic mastitis is supposed to exist are not merely cases in 
which the senile atrophy of the breast has taken place more 
rapidly than usual or began to develop at an earlier age. The 
frequent occurrence of this condition in women who are at the 
menopause, a period during which the mammary tissues are 
most unstable, is certainly suggestive of involuntary changes. 
I believe this is a matter worthy of the most serious considera- 
tion and one to which observation and investigation may well 
be directed. 

The cases occurring in young girls shortly after puberty also 
point strongly to a deviation from the normal process of evolu- 
tion through which the gland goes at this epoch of life. 

From what has been stated it is evident that the etiology of 
chronic mastitis is far from being thoroughly understood, and 
that it is a subject fit for further study. The theories which I 
advance relative to the causation of some of the cases of ob- 
scure origin seem to me to be at least plausible, if not indeed 
affording a reasonable explanation of their development. 

Pathology. — The predominant alteration in structure is an 
increase in fibrous tissue. Two views have been entertained 
in regard to the origin of this tissue; some have held that the 
changes begin in the glandular elements, while others hold that 
the interstitial connective tissue is primarily affected. Konig, 
who formerly favored the latter view, has now come to regard 
the former as correct and accordingly has discarded the term 
interstitial which he employed in referring to chronic diffuse 
mastitis. 

If a section from such a mammary gland be examined 
microscopically, a plentiful distribution of fibrous tissue 
around the ducts will be seen, and furthermore it will be ob- 
served that the masses of fat in the interstitial tissue are com- 
pletely surrounded by the fibrous tissue, being encapsulated, 
so to speak. The new tissue appears in various stages of 



40 Diseases of the Breast. 

development. It is frequently infiltrated with leucocytes in its 
earlier stages. 

Allusion has already been made to the changes occurring in 
the galactophorous ducts. The cysts which are formed are due 
to obliteration of the lumen of the ducts with consequent 
dilatation of the portion remaining patent. They are, there- 
fore, retention cysts, pure and simple. They vary in size, 
some being very minute and others fairly large. In the small 
ones healthy epithelium is seen, whereas in those of larger size 
degenerated cells are sometimes observed. The contents 
of these cysts also varies both as to color and consistency, 
being thin and clear in some instances and viscid and dark 
colored in others. The former condition is the more common. 

It not infrequently happens that a portion of the duct becomes 
completely obliterated and atrophied, being converted into a 
small, dense, fibrous cord. 

In those cases of chronic mastitis following acute inflammation 
or injury, and in which the disease is localized rather than diffuse, 
the fibrous tissue seems to form more rapidly, so that oblitera- 
tion of the ducts without cyst-formation is the rule. Macro- 
scopically such breasts present dense areas of fibrous tissue sit- 
uated in different parts of the gland, their location of course 
depending upon the site of the primary disease. Carcinomat- 
ous degeneration may take place in a breast thus affected; 
when such change occurs the altered glandular tissue will be 
iound imbedded in the dense fibrous tissue everywhere present 
in the section. They may follow the line of the minute l)mi- 
phatics of the breast, as in a case described by Whitney. 

The symptoms and course of chronic mastitis are variable. 
Sometimes it begins suddenly with pain and swelling of the 
breast, while at others its onset is gradual. During the men- 
strual periods the symptoms become intensified. Occasionally 
the symptoms subside after a few months, but as a rule the 
disease is progressive. In the localized form pain and uneasi- 



Inflammatory Diseases of the Breast. 41 

ness in the indurated areas are the only symptoms, and even 
these may be absent. 

In the diffuse form the disease may be mistaken for begin- 
ning scirrhus carcinoma, particularly if the onset has been insid- 
ious. In the absence of a clear history large isolated nodules 
may also lead to confusion with the same form of malignant 
disease. 

Treatment is unsatisfactory, especially in cases developing 
without any well-defined cause. When inflammation and 
induration remain after acute processes, compression and the 
use of iodine and belladonna ointments in equal parts sometimes 
seems to favor resolution. Ichthyol ointment (30 percent) 
may be used instead if preferred. 

Chronic Abscess. 

If an indurated area which is formed during or shortly 
after the puerperium undergoes softening after a period of 
several weeks, instead of continuing to subside, a chronic 
abscess results. Such an indurated area may undergo partial 
though not complete resolution, remain stationary for a long 
time, and then for some unknown reason advance to suppuration. 
In such cases it is not improbable that the virulence of the 
microorganisms becomes attenuated, so that they lie dormant 
until some exciting cause arouses them to renewed activity. 
Another explanation for the development of these slow sup- 
purative processes is afforded by the supposition, that micro- 
organisms transmitted through the blood lodge in the tissues of 
the mammary gland, the vitality of which has been impaired 
by previous disease, and set up a low form of inflammation. 

Whatever the origin of these chronic abscesses, whether they 
are residual processes of acute inflammation or develop from 
causes which are indeterminable, an essential fact to remember 
is that they merely represent a slow form of suppuration. 

Sometimes an injury may be followed after the lapse of 



42 Diseases of the Breast. 

weeks or months by the formation of an abscess, which in all 
probabihty is due to the lowered power of resistance in the 
tissue caused directly by the injury, the changed condition 
resulting therefrom being favorable to the growth of micro- 
organisms. 

The development and duration of these abscesses is most 
variable. 

Klotz has reported a case in a woman, twenty years of age, 
who had suffered two years before with an acute mastitis, 
from which, however, she apparently had completely recovered. 
A hard nodule appeared in her breast, slowly increased in 
size, and finally began to soften. This mass was incised and 
proved to be a sack filled with pus. Even more remarkable 
than this is a case reported by Reclus. In this case a nodule 
which developed shortly after delivery remained stationary for 
six years and then suppurated. 

These abscesses vary in size, although as a rule they do not 
become larger than a hen's egg. They may be irregular in 
form or round and well defined. The skin may or may not 
become adherent. In either case the abscess is movable with 
the rest of the gland. Tenderness to pressure is a constant 
symptom, and enlargement of the axillary glands is also very 
common. 

A chronic abscess has been mistaken for malignant disease, 
particularly sarcoma. The slower development, the associated 
pain and enlargement of the axillary glands, together with the 
history of the case will serve to distinguish it from sarcoma. 
Abscess is differentiated from carcinoma by its more rapid 
development, the earlier involvement of the axillary glands, and 
the invariable tenderness to pressure. 

Treatment consists, of course, in free incision and drainage. 



TUBERCULOSIS. 

Although Virchow in his treatise on the Pathology of 
Tumors included the mammary gland among the organs not 
subject to tuberculosis, reference to scrofulous affections of 
the breast had been made long before by Sir Astley Cooper, 
and Velpeau had also discussed tuberculous tumors in a vague 
and indefinite manner, recognizing, however, three forms, 
which he called disseminated tumor, lymphatic tumor, and 
lymphatic degeneration. Other surgeons also reported a case 
now and then, but it was not until 1881 that Dubar made the 
first scientific study of the disease. To him belongs the credit 
of first demonstrating the tubercle bacillus in the mammary 
tissues. Ten years later Roux called attention to intramam- 
mary cold abscess. 

Although rare, tuberculosis of the breast is probably moire 
common than it has been considered to be. In more than 
fifteen hundred cases of disease of the mammary gland ad- 
mitted to St. Bartholomew's Hospital, London, Sidney R. Scott 
found 1.5 percent to be tuberculosis. While it is true that the 
number of cases occurring in literature which have been veri- 
fied by finding tubercle bacilli or tubercles in the tissues exam- 
ined is small — Schley having found only sixty-five up to 1903 — 
it is probable that more careful observations will prove the dis- 
ease to be commoner than it has usually been thought to be. 

As in other organs, so in the mammary gland, tuberculosis 
may be primary or secondary. Although it is true that the 
disease cannot positively be stated to be primary unless an 
autopsy be held and the presence of a concealed tuberculous 
focus excluded, still for practical purposes those cases in which 

43 



44 Diseases of the Breast. 

there are no other demonstrable foci may be regarded as 
primary. 

In this form the infection no doubt takes place through 
the blood current or results from direct infection from without. 
The latter mode is no doubt rare. That tubercle bacilli might 
gain access to the mammary gland through an open wound or an 
abrasion is, of course, not to be disputed, and that there is a 
possibility of their gaining entrance through the galactophorous 
ducts is likewise not to be denied. Indeed the latter mode 
of entry has been strongly upheld by Verneuil. So far as I have 
been able to determine, however, the lesions are more pro- 
nounced in the alveoli than in the ducts, and, moreover, the 
ducts themselves are generally not more diseased near their exit 
at the nipple than they are further in the interior of the gland. 
Were the infection to take place through these ducts it is only 
natural to suppose the primary lesion would develop close to 
their orifices and that the disease would be more advanced there 
than in the parenchyma of the gland itself. While no decisive 
statement can be made in regard to this matter until further 
observation, based upon a greater number of cases, has been 
made, in view of the chief location of the morbid process, and 
likewise in consideration of our knowledge of the mode of tuber- 
culous infection in other organs of the body, particularly the 
geni to-urinary organs, I am of the opinion that the usual mode 
of primary infection of the mammary gland is through the blood 
current. In this connection it is interesting to note that Kitt, 
who has studied bovine tuberculosis thoroughly, states that 
tuberculosis of the udders is almost always of hematogenous 
origin. 

When secondary the infection may extend from neighboring 
structures, as, for instance, the pleura or ribs, or it may be trans- 
mitted through the blood current from a focus in a remote por- 
tion of the body, or be carried by the lymphatics from a diseased 
gland in the axilla or in the supraclavicular triangle. 



Tuberculosis. 45 

Halsted believes that invasion by way of the lymphatics 
constitutes the primary mode of infection, even maintaining 
that those cases which are usually considered primary are in 
reality secondary, being due to the transference of tubercle 
bacilli from other parts of the body, principally the axillary 
and mediastinal glands, through the lymph stream. 

Considerable has been written concerning the relative fre- 
quency of the primary and secondary forms, and much differ- 
ence of opinion has been expressed. As has already been said, 
it is impossible to state positively that a case is primary, unless 
every organ of the body can be examined and the absence of 
tuberculous foci excluded. In regard to the relative frequency 
of those cases which are denominated primary because there 
are no other demonstrable lesions, and those in which it is plain 
that the disease is secondary, it is evident that a larger number of 
observations must be made before any definite conclusions can 
be drawn. 

Some difference of opinion has been expressed as to whether 
the disease begins within the acini or in the connective tissue, 
but the weight of evidence is strongly in favor of the former 
view. 

Concerning the etiology of mammary tuberculosis, it may 
be said that the disease occurs much more frequently in females 
than in males, and that it affects young women oftener than it 
does those of middle or old age. It may, however, occur at 
any period from puberty to senility. As a greater number of 
cases are reported it may be found that the disease shows a 
greater predilection to develop during a certain decade than at 
any other time. Out of thirty-two cases studied by Delbet, 
eighteen were in women between the ages of twenty-five and 
thirty-five. Schley found the disease to be equally common 
during the third, fourth and fifth decades. Of eleven cases 
recently reported from Bruns' clinic at Tubingen one occurred 
in the twenty-fifth year of life, four in the thirtieth, four in the 



46 Diseases of the Breast. 

fortieth, and two in the fiftieth. It has been stated that no 
cases have been observed after the menopause, but in looking 
over the Hterature of the subject I found one reported in a 
woman of seventy. 

Heredity seems to exert no greater influence, if indeed it be 
as great, than in the production of tuberculosis in other organs 
of the body. 

Previous inflammatory diseases and injury are naturally to 
be considered as predisposing causes. By lowering the vital- 
ity of the mammary tissues they, no doubt, prepare a favorable 
soil for the reception and growth of the specific microorganisms. 

Tuberculosis in other parts of the body of course predisposes 
to secondary involvement of the breast. Thus, Mandry found 
an associated tuberculous affection in one-half of the cases 
which he studied. 

Some investigators have attributed a considerable influence 
to pregnancy and lactation as predisposing factors, whereas 
others have flatly denied that they are of any etiological sig- 
nificance whatsoever. It is probable that the only causative 
effect which can reasonably be attributed to these processes 
is a secondary one, that is, they predispose to tuberculous infec- 
tion only in so far as they lower the vitality of the mammary 
tissues by giving rise to inflammation or abscess, and thus pro- 
duce a more favorable soil for the reception and growth of any 
tubercle bacilli which perchance may gain access to the gland. 

Pathology. — A discrete and confluent form are usually recog- 
nized. In addition to these two forms intraglandular mammary 
abscess and miliary tuberculosis have been described. The 
last mentioned occurs as a part of a general miliary tubercu- 
losis and, therefore, may be dismissed from further consid- 
eration. 

In the discrete form there are a few isolated tubercles which 
are separated by apparently healthy tissue. These tubercles 
may undergo the ordinary changes which occur in aU tubercles 



Tuberculosis. 47 

and still remain isolated, or, owing to the dissemination of in- 
fection from them, new tubercles may form in the intervening 
healthy tissue so that a larger area becomes involved. If the 
morbid process advances, coalescence of these tubercles may 
take place and the confluent form of the disease result. Indeed 
any difference between the two usually recognized forms of 
mammary tuberculosis has been denied, and it seems not 
improbable that the actual difference is in the degree of inten- 
sity of the infection and the resistive power of the tissues rather 
than in the morbid process itself. 

The isolated tubercles vary in size, some being no larger 
than a pea while others are as big as a hazel-nut. If caseation 
and liquefaction occur abscesses develop. 

In the confluent form a swelling of considerable size is pres- 
ent in the breast. This tumefaction, however, is often not 
sharply limited, being ill-defined and irregular and presenting 
bosselations over its surface. WHien cut into during the early 
stages of its evolution such a tumor is found to be of a white 
or grayish color and of firm consistency. In the later stages, 
although this appearance may still be retained at the periphery, 
the center will have become yellow in color. If liquefaction 
occurs, an abscess is formed, the so-called intramammary 
cold abscess of Roux. In some cases softening and lique- 
faction is limited to certain parts of the tumor, so that small 
abscesses alternate with areas of indurated tubercle. It may be 
that the greater portion of the tumor has undergone liquefaction, 
but that certain portions have remained intact, persisting as 
trabeculae between the various cavities of the abscess. The 
waUs of a tuberculous mammary abscess do not differ from 
those of a tuberculous abscess in other soft tissues, being thick 
and lardaceous and covered with granulations and tubercles. 

The microscopic appearance of a mammary gland affected 
with tuberculosis varies according to the stage of the disease 
in which it is examined. If seen at the very beginning it is 



48 Diseases of the Breast. 

probable that no changes other than simple inflammation could 
be detected. Early in the development of the morbid process 
the alveoli and ducts are still discernible and plainly recogniz- 
able. Later the alveoli disappear, granulation tissue is dis- 
seminated throughout the lobule, and giant cells are seen. 
There may be such an infiltration of embryonal tissue in the 
interstices between the alveoli as completely to destroy the lat- 
ter structures. This new tissue also contains giant cells. Some- 
times beginning tubercle-formation can be detected in adjoining 
lobules. The same changes occur around the ducts, although 
the alveoli are first attacked as a rule, the embryonal tissue 
compresses or invades these structures, just as it does the alveoli, 
and thus leads to their partial or complete destruction. In some 
sections studied, only the changes of simple inflammation were 
apparent around the ducts, although the typical alterations of 
tuberculosis involved the alveoli. The walls are thickened by 
an infiltration of leucocytes which may even extend into the 
lumen of the ducts. Granulations may also be present. Tuber- 
cle bacilli are very rare in the tissue and many sections may be 
examined before any are found. The diseased tissue is also 
poor in blood-vessels. 

Four cases of tuberculosis of the breast associated with 
carcinoma have been recorded, and one associated with adenoma 
has also been reported by E. P. Davis. In the first class the 
symptoms of tuberculosis predominated and the macroscopic 
appearance of the diseased tissue was suggestive of tuberculosis 
rather than of mahgnant disease. Microscopic examination, 
however, demonstrated the presence of carcinoma cells in the 
diseased area. 

Two of these cases were reported in the American Journal 
of the Medical Sciences, July, 1899, by A. S. Warthen, of 
Ann Arbor, Michigan. In one case it is probable that tuber- 
culosis constituted the primary lesion; in the other, however, 
the carcinoma was undoubtedly primary. 



PLATE III. 




Tuberculosis. Microscopic appearance. {Drawing made from a specimen 
loaned hy Dr. A. O. J. Kelly, of Philadelphia.) 



Tuberculosis. 51 

Pilliet and Piatot {Bull, de la Soc. Anat. de Paris, May, 
1897), reported another case occurring in a male aged fifty-one 
years. 

The fourth case was reported by Kallenberg in his Tubingen 
thesis for 1902. 

Rokitansky's teaching that carcinoma and tuberculosis 
never occur simultaneously is now known to be erroneous, and 
Rokitansky himself modified his theory as far as to admit that, 
though exceedingly rare, the two might be combined. A 
number of cases are on record in which the two have been found 
associated in different organs of the body. 

That their simultaneous occurrence in the mammary gland 
is most unusual is shown by the paucity of cases thus far re- 
ported. Kallenberg was unable to find a single case recorded 
in German literature at the time he wrote his thesis in 1902. 

Whether the combination is entirely fortuitous or whether 
one lesion gives rise to the other is unknown. Whether the 
irritation produced by tubercle sets up an abnormal prolifera- 
tion of epithelial cells resulting in the formation of a malignant 
neoplasm or whether tuberculous infection is superimposed 
upon the carcinomatous process has not been positivelv deter- 
mined. 

This combination of tuberculosis and carcinoma is so rare 
that it is of pathological rather than clinical interest. 

Symptoms. — The onset of tuberculosis of the breast is insidi- 
ous and its development usually slow, although lactation seems 
to stimulate the morbid process to more rapid growth. The 
disease may last for months or years. It is remarkable that 
only one breast is affected. 

In the discrete form areas of induration are detected in var- 
ious portions of the gland, in some cases being distinctly separ- 
ated from the surrounding tissue, while in others the outline is 
indistinct. In this form there is not much enlargement unless 
nodules situated close to one another coalesce and soften, in 



52 Diseases of the Breast. 

which case the products of hquefaction may give rise to a dis- 
tinct tumor. 

Isolated tubercles vary considerably as to their evolution. 
They may remain stationary for a considerable time or grad- 
ually increase in size. 

Early in the disease the skin is not adherent, but often 
becomes so in the later stages. Fistulae may also form. Pain, 
too, is usually not severe at first, although it may become so as 
the morbid process progresses. 

The confluent form is of more rapid evolution, fistulae form- 
ing much earlier than in the discrete form. A solid mass is 
present, varying in size from a walnut to an orange, and being 
hard or soft according to the stage in which it is examined. 
The outline of such a tumor is usually not clearly defined, but 
somewhat irregular. The most common site is the superior 
external quadrant. In the majority of cases the axillary glands 
are enlarged. They generally increase rapidly in size and may 
■go on to suppuration. Retraction of the nipple due to sclerosis 
of the subjacent tissues has also been seen. 

The tendency of these tuberculous areas is to liquefaction 
and abscess-formation. 

Variations from the usual manifestations of the disease as 
above described have been observed. Thus, for instance, 
Orthman saw a case in which the infection apparently occurred 
from without, the first lesion which appeared resembling a 
simple furuncle. Instead of healing, however, its base became 
ndurated, and as it progressed in its development its true na ture 
was revealed. Kramer has reported a case in -which the dis- 
ease began as an ulceration of the nipple. 

Such manifestations, however, are unusual. 

Diagnosis. — The diagnosis of mammary tuberculosis may 
be very difficult. This is particularly true of the cases which 
are seen early, before much or any destruction of tissue has taken 
place. Naturally those cases in which fistulae are present. 



Tuberculosis. 53 

together with marked enlargement of the axillary glands, offer 
less difficulty than those seen at an earlier period of their evolu- 
tion. It is likewise the case when tuberculous foci in other 
parts of the body can be readily detected. A tuberculous 
abscess has been mistaken for a cyst, and also for a chronic 
abscess. In tuberculosis, however, the usual pronounced en- 
largement of the axillary glands will serve as a point of differen- 
tial diagnosis. 

In the early stages the disease might be confused with 
actinomycosis, although in the later stages the presence of the 
ray-fungus in the discharge would afford a positive means 
of differential diagnosis. 

A few isolated tubercles might also be mistaken for syphil- 
itic lesions, but the history and progress of the case and the 
failure of antisyphilitic treatment would reveal the true nature 
of the affection. 

Cases of tuberculosis have been mistaken for carcinoma, 
and vice versa. In carcinoma the early adherence of the tumor 
to the skin, the slower enlargement of the axillary glands and 
their greater hardness are circumstances valuable in distinguish- 
ing between the two affections. 

The age of the patient should also be taken into consideration, 
as the majority of carcinomata occur in women after middle life. 
Tuberculosis, however, seems to show a greater predilection 
for young women, although many cases have occurred in women 
past forty. 

Prognosis. — In cases in which no other tuberculous lesions 
are present the prognosis may be considered good, provided 
all the diseased tissue is removed and the axilla thoroughly 
freed of enlarged glands. Recurrences, however, have been 
known to take place. 

In cases in which other demonstrable tuberculous foci are 
present the prognosis is of course somewhat influenced by the 
nature and extent of these lesions. As regards the effect of the 



54 Diseases of the Breast. 

morbid process upon the gland itself, it will suffice to say that 
extensive destruction of tissue may result. Some interesting 
statistics bearing on prognosis have recently been reported by 
Braendle, one of Bruns' assistants at the Tubingen clinic. Out 
of sixteen patients whose history was folio wed ■ after operation 
fifteen were cured. The time elapsing from operation to the 
publication of his report varied from one to nineteen years. 
Of these fifteen patients three succumbed to phthisis a number 
of years after operation; no local recurrence, however, took 
place. In no case was the other breast involved. 

Treatment. — Tuberculosis of the mammary gland has been 
treated by curetting and cauterizing the sinuses, by excising a 
wedge-shaped portion of the gland containing the diseased 
area, and by amputating the breast. It remains to be shown 
that anything short of amputation is a certain and safe proce- 
dure, inasmuch as no one can tell whether the disease is not 
already implanted in portions of the breast which are apparently 
healthy, so that recurrence may take place even though it seems 
that all diseased tissue has been removed. Notwithstanding 
this fact I believe it justifiable to practise partial resection in 
the discrete form of the disease and even in those diffuse cases 
in which a considerable portion of the breast is apparently 
uninvolved. Such a course of procedure may save the patient, 
often a young unmarried woman, from a needless mutilation, 
which would seriously impair her chances of matrimony. 
The favorable results obtained by this procedure have been 
attested by the experience of a number of surgeons. Many 
good surgeons are now advocating resection of the epididymis 
in cases of tuberculosis affecting the testicle as well as this 
organ, believing that Nature will complete the cure after the 
primary focus has been removed. Certainly a similar conserva- 
tive procedure is worthy of trial in mammary tuberculosis. Any 
signs of recurrence caU for immediate amputation of the breast. 
The axilla should always be cleared of all diseased glands. 



Tuberculosis. 55 

If operation be refused, injections of an ethereal solution of 
iodoform may be made into the diseased area. Cuneo states 
that intramammary cold abscess yields more readily to this 
treatment than other forms of mammary tuberculosis. 

At the present day probably no article upon the treatment 
of local tuberculosis would be complete without some men- 
tion being made of Wright's bacterial vaccines, which are used 
in conjunction with a careful observation of the opsonic power 
of the blood. Wright discovered in the serum of the blood a 
substance named by him "opsonin," which appears to act upon 
the bacteria in such a manner as to render them easy prey 
for the phagocytic leucocytes of the blood, and without which 
the leucocytes are feebly or negatively phagocytic to the bac- 
teria. He also found that by introducing minute but carefully 
estimated doses of the dead bacteria, he could increase the 
amount of this substance in the blood and render the leucoc3^es 
still more active than before. 

It is said that this treatment has proved beneficial in almost 
all varieties of local tuberculosis, and although I have no 
knowledge of it having been used in mammary tuberculosis, 
there is no reason to doubt that it would do good in this 
form of the disease as well as in others. I wish to state dis- 
tinctly, however, that it should not be used as a substitute for 
operation, which has been proved to be efficacious, but as a 
supplement to operation, with the view of hastening recovery 
by increasing the opsonic power of the blood. I am also 
inclined to consider it applicable to cases in which operation 
is refused and injections of iodoform fail to do good. 

The vaccine used is the New Tuberculin Koch (bacilli emul- 
sion) commonly known as Tuberculin R. It consists of the 
triturated bodies of tubercle bacilli suspended in glycerin. It 
should be administered by a competent laboratory expert, 
who is required to make frequent estimations of the opsonic 
power of the blood, so that the injections can be properly 



56 Diseases of the Breast. 

timed in order to avoid obtaining an accumulative depressant 
effect instead of the desired increase in the opsonic power. 
When the dose which will increase the opsonic index is deter- 
mined, it is administered h)^odermatically whenever the blood 
shows any tendency for the opsonic power to fall. It is not 
necessary to increase the dose limit further. 

Another method of treatment which has proved of value, 
especially in the hands of its originator, is Bier's passive hyper- 
emia. This method has given especially good results in all 
kinds of chronic fistulae, tuberculous and otherwise. It is 
applied to regions like the breast by specially devised apparatus, 
that for the breast consisting of a large hemispherical glass 
vessel, slightly larger than the breast itself. In the dome of 
the vessel is a round aperture with a glass nipple attachment. 
To this is attached a rubber tube which is connected with a 
suction pump. 

The apparatus is placed over the affected breast and suffi- 
cient negative pressure created by the pump to cause a red 
hyperemia, not allowing the skin to become blue or pale. 
It is left on for five minutes, then removed for five minutes, 
after which it is reapplied for another five minutes, etc. This 
alternation is continued for forty-five minutes daily. It 
causes a hypernutrition of the part and stimulates all repara- 
tive processes. 

Passive hyperemia might be advantageously combined 
with Wright's vaccination method, for it is asserted that in 
these tuberculous sinuses the serum in the region of the mor- 
bid process has a lower opsonic index than in the remainder 
of the body. After several treatments with the Bier's appa- 
ratus, the local opsonic index is brought up to the standard of 
the general index. If we raise the general index above the 
normal we may, by combining the two methods of treatment, 
also increase the local index above the normal and greatly 
hasten, the healing of the sinus. 



SYPHILIS. 

Syphilis may affect the mammary gland in its primary, 
secondary, or tertiary stage, and may occur in either sex, 
although it is far more common in females than in males. 
Fournier, whose experience is unrivaled, had seen only three 
cases in men up to 1897, when his classical work on extra- 
genital chancres was published. 

In regard to the frequency of primary mammary syphilis 
as compared with other extra-genital forms of the disease, a 
series of cases recently reported by Ivanyi, of Buda Pest, 
is of interest. Out of 138 cases of extra-genital syphilis he 
found that only 6, or 4.34 percent, were of mammary origin. 
Thus it is seen that primary mammary S3^hilis is rare. 

The initial lesion of syphilis as it affects the female breast 
is most common in nursing women, being produced by inocula- 
tion with the syphilitic virus from the mouth of an infant 
suffering with the disease. Infants affected with hereditary 
syphilis often convey the disease to wet-nurses, who in turn 
transmit it to other children whom they suckle; and these 
infants then become capable of disseminating infection among 
other wet-nurses to whose breasts they may perchance be put. 

A nurse tainted with constitutional syphilis contracted 
through sexual intercourse may also infect a nursling, who 
of course becomes an immediate source of contagion to all 
those with whom it comes in contact, but particularly to its 
mother or other women who may nurse it. Thus it is seen 
that a single syphilitic infant or a single syphilitic wet-nurse 
may be the means of infecting a multitude of innocent persons. 
Epidemics of syphilis originating in this manner have been re- 
ported, especially in France and Italy, and many households 

57 



58 Diseases of the Breast. 

have been rendered syphihtic in the same way, even when the 
original disseminator of the disease was apprehended and pre- 
vented from distributing the loathsome malady promiscuously. 

This manner of conveying syphilis was well recognized by 
Ambrose Pare, who describes an instance in which a syphilitic 
wet-nurse infected an infant, who in turn infected its mother, 
with the result that its father contracted the disease. Later 
two other children became infected, presumably by eating or 
drinking from the same dishes used by the father. 

In addition to this, the common mode of infection of the 
breast, there are cases on record in which the malady has 
been conveyed through the diseased mouth of a syphilitic 
adult. It was to this form of infection that Ricord caustically 
applied the expression ^^ contagion par nourrison aduUe.^^ 

In persons of uncleanly and careless habits infection might 
easily be transmitted through the medium of towels, hand- 
kerchiefs, or articles of wearing apparel, which had been con- 
taminated with the syphilitic virus. Whether such cases have 
actually occurred I do not know, but the possibility of their 
occurrence is worth bearing in mind. 

One or both breasts may be infected and the initial lesion 
may be multiple. Thus, for example, Keyes has observed a 
case in which there were twelve chancres, eight on one breast 
and four on the other. 

This multiplicity of lesions is not surprising when we come 
to consider the conditions in the lactating breast favoring 
infection. The various erosions and fissures so often present 
serve as admirable portals of entry for the syphilitic poison, 
and the repeated applications of the child to the breast furnish 
a frequent source of fresh infection. 

In regard to the location of the initial lesion, it has been 
found that the most common site is at the junction of ,the 
nipple and areola, although it may be situated upon the nipple 
itself, upon any part of the areola, or upon the cutaneous 



Syphilis. 59 

surface of the breast. The last named site, however, is very- 
rare. 

Fournier, who has had the opportunity of observing incipient 
mammary chancre in four cases, describes three different 
forms: i, a very minute round cutaneous elevation, smaller 
than a lentil; 2, a dark red cutaneous elevation; 3, a cuta- 
neous elevation the center of which soon becomes desquamated 
and eroded, and is smaller than the head of a pin. This form 
of initial lesion looks more like an abrasion than anything 
else. 

The fully developed mammary chancre may be incrusted 
or open. In the latter instance it may present the appear- 
ance of a fissure or show signs of well-marked ulceration. 
The latter form is not uncommon. Occasionally mammary 
chancre may become phagedenic, particularly in debilitated 
women. 

Thus it is seen that the primary lesion is often at3^ical. 
This circumstance renders diagnosis difficult, particularly 
in the early stages of the sore. When any doubt exists, the 
safest thing to do is to consider the lesion syphilitic until time 
proves it not to be. By so doing the spread of contagion 
may be checked. 

Paget's disease may resemble an ulcerating chancre in some 
respects, but its slower evolution and the absence of axillary 
involvement serve to distinguish it from the latter. 

A thorough and careful examination would prevent con- 
fusion of a phagedenic chancre with malignant disease. Other 
signs of syphilis would be found, or would develop while the 
case was under observation. 

Mammary chancre gives rise to enlargement of the axillary 
glands, and in course of time the ordinary secondary signs of 
syphilis develop. 

Some have maintained that constitutional syphilis following 
mammary chancre is often more severe than that developing 



6o Diseases of the Breast. 

after inoculation through other portions of the body. These 
observers evidently overlook the fact that many subjects of 
mammary chancre are ill-nourished, overworked, and debilit- 
ated, so that they are unable to withstand the encroachment 
of their infection as well as the more fortunate persons in the 
better walks of life who contract their syphilis in the more 
usual way. Certainly there is no reason to believe that syph- 
ilis following a mammary chancre would be more violent than 
that developing after any other form of initial lesion, provided 
that the individual's powers of resistance are not below par. 

In addition to the ordinary cutaneous eruption of secondar}^ 
S3^hilis which may appear on the breast, the softness of the 
skin, the moisture, and the friction of the two opposing sur- 
faces at the junction of the breast and thoracic wall, all favor 
the development of moist syphihdes, particularly in women 
whose breasts are pendulous and who are of uncleanly habits. 
These lesions may appear as groups of papules, or as spots 
of various size, resembling mucous patches. Occasionally 
the latter form may cover the entire inferior surface of the 
gland or even extend to the chest-wall. 

Papular syphilides and mucous patches are also found 
on the areola and nipple. 

Tertiary syphilis may affect the mammary gland in the 
form of gummata, diffuse inflammation, tubercles, rupia and 
ulcers. Both sexes are subject to this stage of the disease, 
although it is more frequently seen in women than in men. 

Gummata may occur in any part of the breast, appearing 
as hard, circumscribed tumors, which form insidiously and 
increase in size slowly, so that they do not attract much atten- 
tion during the early stages of their evolution. In the later 
stages, however, they show a tendency to soften and break 
through the skin. As the process of softening advances the 
tumors become adherent to the skin, which assumes a dark 
congested appearance and later gives way to allow the escape 



Syphilis. 6i 

of the products of hquefaction beneath. At this period the 
axillary glands are found to be enlarged. 

Such softened gummata have been mistaken for cysts, and 
their true nature revealed only at the time of operation. 

In their early stages gummata may be mistaken for benign 
tumors, particularly if there are no signs of syphilis in other 
parts of the body. Likewise there may be difficulty in separat- 
ing them from malignant growths after they have become 
adherent to the skin and enlargement of the axillary glands 
has occurred. Under these circumstances a careful examina- 
tion for other signs of syphilis and interrogation of the patient 
in reference to a previous syphilitic infection may prove of help 
in making a differential diagnosis. A history of previous 
nodules or masses in the breast which have disappeared 
without treatment is suggestive of S3^hilis, provided that 
inflammatory affections can be excluded. At all events the 
progress of the case will reveal its true nature. The therapeutic 
test, preferably in the form of hypodermatic injections of 
mercury bichloride and large doses of iodides internally, 
may be tried in doubtful cases. Gummata usually soften and 
rupture within a few months after they are first detected, their 
course thus being much more rapid than that of carcinomata. 

In diffuse syphilitic inflammation of the breast a portion of or 
perhaps the entire gland is enlarged, hard, and sometimes pain- 
ful. This form of mammary syphilis is not a remote manifes- 
tation of the disease, but usually occurs during the latter part 
of the secondary stage. It has been known to develop shortly 
after the first appearance of the secondary rash. The period 
of its incidence thus makes diagnosis comparatively easy. 

As considerable evidence has been accumulated to show that 
the spirocheta or spironema pallida may be the specific cause 
of syphilis, in doubtful cases scrapings from the lesions, as 
well as the tissue juices and blood, should be examined for 
this organism. To stain for the spironema in coverglass 



62 Diseases of the Breast. 

spreads, the scrapings from the lesions or the tissue juices 
from their center are spread thinly over the glass and then 
dried in the air, after which they are fixed for ten minutes in 
absolute alcohol and then treated with the following modifi- 
cation of Giemsa's azur-eosin stain freshly prepared: — (i) 
12 parts of Giemsa's eosin solution (2.5 cc, i percent eosin 
solution in 500 cc. of water) ; (2) 3 parts azur I (i-iooo water) ; 
(3) 3 parts azur II (0.8-1000 water). It is left in this stain 
for sixteen to twenty-four hours, washed for a short time in 
water, dried, and examined in cedar oil. 

The organism can be recovered from the blood by Noegerath 
and Staehlin's method, which consists in taking i cc. of blood 
and 10 cc of a J percent solution of acetic acid, mixing them, 
centrifuging, and examining the deposit. 

The spironema is a very delicate spiral organism, weakly re- 
fractile, having flagella at both ends, and measuring from 4 to 20 
microns in breadth. The spirals are very narrow and regular. 

In regard to the treatment of mammary syphilis there is 
little to be said. The usual antisyphilitic treatment with 
mercury and the iodides is to be employed, and as a rule 
causes the lesions to yield rapidly. Chancres of the breast 
require little treatment other than cleanliness. If of the 
ulcerative type they may be dusted with calomel and bismuth 
subnitrate, equal parts, whereupon they will soon become 
healthy and heal. 

Gummata yield readily to mixed treatment, or to inunctions 
of mercury and large doses of the iodides internally. 

In poorly nourished, debilitated women, every effort should 
be made to build up the general health by means of generous 
diet and the use of bitter tonics, or iron and arsenic, in addition 
to the use of specific medication. 

It is hardly necessary to say that the most careful prophy- 
lactic measures should be taken to prevent the propagation 
of the disease by women thus affected. 



ACTINOMYCOSIS. 

Actinomycosis of the breast is rare, although a few authentic 
cases are on record. The disease may be either primary 
or secondary, infection occurring from without through a 
wound or abrasion, or extending from other organs of the 
body, for example, the lungs or pleura. 

The primary wound may heal and actinomycosis break 
out later. 

The invading parasites set up inflammation, as a result 
of which the skin over the gland becomes reddened and 
breaks down, sinuses form, and pus containing the actinomyces 
is discharged. The substance of the gland may be destroyed, 
and in cases in which the infection occurs from without the 
pectoral muscles may be invaded and even the ribs attacked. 
Metastases may also occur. 

Mammary actinomycosis is very rebellious to treatment, 
and the most active measures should always be adopted to 
combat its inroads. 

The greatest danger is to be apprehended from the devel- 
opment of metastases. 

The only rational procedure is to remove all the diseased 
tissue, cutting well into the healthy portion of the gland. 
It may be necessary to amputate the breast. Large doses 
of potassium iodide should be given. 

When the disease is secondary the chances of cure are 
less favorable than in the primary form. In a secondary case 
reported by Nelaton, however, the patient overcame the 
disease to the extent of regaining her general health, and this 
despite the fact that a periodic discharge of pus containing 
actinomyces occurred not only from a small sinus in the 
breast, but also from others in the lumbar region. 

63 



CYSTS. 

Much confusion has prevailed in regard to the etiology 
and pathology of mammary cysts. First of all it is necessary 
to distinguish true cysts from neoplasms which have under- 
gone cystic degeneration, and it is only the former which will 
be considered here. The latter will be discussed in connec- 
tion with tumors. 

We recognize the following varieties of mammary cysts: 
single retention cyst, lymphatic cyst, general cystic disease, 
galactocele, echinococcus-cyst, and dermoid cyst. In ad- 
dition to these varieties sebaceous cysts of the areola have 
occasionally been observed. 

Single Retention Cyst. 

This form of mammary cyst, which is not uncommon, 
is due to occlusion of a galactophorous duct by the products 
of inflammation. Thus previous disease of the breast or injury 
may alike be responsible for the obstruction of the lumen of 
the duct, which leads to dilatation of the remaining free por- 
tion. 

These cysts vary in size, some being no larger than a marble, 
while others are as big as a small orange. They do not differ 
from cysts formed in other glandular organs by occlusion of 
the excretory ducts, being of comparatively rapid formation, 
and appearing in the breast as regular round or oval swellings 
of elastic consistency. Fluctuation may be plainly detected 
in most cases. Pain, tenderness, and involvement of the 
axillary glands are absent. 

The fluid contained in these cysts is serous and varies in 
color from light yellow to reddish or brown. Discoloration 

64 



Cysts. 



65 



of the fluid is probably due to solution of blood coloring matter 
from occluded vessels in the wall of the cyst. 

The wall is thin and the surrounding tissue is normal in 
every respect. 

Treatment consists in dissecting the cyst out in its entirety. 



K 



> 





Fig. 13. — Large retention cyst of left breast. 

Lymphatic Cyst. 

This form of cyst, which has been described by Birkett 
and later more carefully studied by Labbe and Coyne, is 
due to the accumulation and retention of fluid in the lymph- 
spaces in the connective tissue of the mamma. Lymphatic 
cysts may be either single or multiple and occur as firm, hard 
masses of round or oval shape, being usually about the size 

5 



66 Diseases of the Breast. 

of a hazel-nut. Fluctuation is absent as a rule, and neither 
pain nor tenderness to pressure are present. The axillary 
glands are not involved. 

The contents of these cysts is clear, pale yellow fluid, and 
the wall is lined with a single layer of flat epithelial cells. 

Treatment consists in dissecting out the cyst exactly as is 
done in single retention cyst. 

General Cystic Disease. 

Of all the diseases to which the mammary gland is subject 
there is not one concerning which so much confusion has 
prevailed as this one, nor any to which such a variety of names 
has been applied. Although multiple cyst-formation in the 
breast has long been recognized, its pathology has been sur- 
rounded with obscurity, and various theories have been for- 
mulated in explanation of its cause and development. 

Sir Astley Cooper recognized this condition, but erroneously 
called it hydatid disease. Sir Benjamin Brodie also gave 
a good description of it. He considered it to be due to dilata- 
tion of the galactophorous ducts. It is most interesting to 
note that this acute observer plainly recognized the pro- 
gressive nature of the affection, and called attention to the 
fact that it assumes a totally new character as it proceeds. 
This observation is of particular interest in the light of our 
present knowledge, and especially as concerns the views to be 
enunciated here relative to the pathogenesis and nature of 
the disease. 

Despite the contribution of these two surgeons little atten- 
tion was given to the disease until i860, when Reclus published 
an account of it, calling attention to the frequency with which 
both breasts are affected, the hardness of the diseased areas, 
and the absence of a well-defined tumor. He made further 
contributions in the years 1883 and 1887, and maintained 
that the disease was due to proliferation of the glandular 



PLATE IV. 




O 



Cysts. 69 

epithelium. Although Reclus gave it the name of intra- 
acinous cystic epithelioma, it has frequently been called Reclus' 
disease, or simply cystic disease of the breast. 

Following Reclus' contributions numerous investigations 
were carried on, principally by French and German surgeons 
and pathologists, with the result that other theories in regard 
to the origin and nature of the disease were advanced. 

Tillaux and Phocas described the same condition under the 
name of maladie noueuse, and asserted that it was a chronic 
mastitis with formation of fibrous tissue. Rochard main- 
tained that the condition was merely the expression of any 
one of a number of different pathological processes. Many 
differed from Reclus in regard to the close relation of the 
disease to carcinoma, notably Quenu and Verneuil. Others 
advanced the theory that the process was primarily inflam- 
matory. In Germany Schimmelbusch made a study of the 
subject with the result that he decided the cysts were due to 
new formation, and added the name of cystadenoma to the 
list of those already in vogue. To increase the multiplicity 
of terms Sasse proposed the name of epithehal polycystoma, 
holding that the term cystadenoma was inadequate, inasmuch 
as the process is much more diffuse than an ordinary neoplasm, 
and is also especially characterized by epithelial formation. 

In the article on chronic mastitis it was stated that in 
the diffuse form of that disease multiple cysts of the most 
various size were found dispersed throughout the mammary 
tissues, and it was furthermore stated that they were reten- 
tive cysts pure and simple, being due to the occlusion of the 
ducts by thickened fibrous tissue. Moreover, attention was 
called to the diversity of opinion which existed in regard to 
the location of the primary changes which occur. The con- 
dition of the epithelium within these cysts was also mentioned, 
it being stated that in some, particularly the smaller ones, it 
was normal, whereas in others proliferation could be plainly 



70 Diseases of the Breast. 

seen. The views set forth concerning the etiology of diffuse 
chronic mastitis will also be remembered. In brief it was 
stated that deviations from the normal functional activity 
of the gland, accompanied as they must be by alterations of 
structure, and particularly the changes and aberrations to which 
it is subject during pregnancy, lactation, and the period of 
involution, were responsible for the abnormal condition then 
under discussion. 

What I wish to declare in this place is that I believe chronic 
diffuse mastitis with cyst-formation, and general cystic disease 
of the breast, to be one and the same disease. The only 
difference which exists is a difference in degree, and the reason 
for describing the stage in which cyst-formation reaches its 
height apart from the earlier stages of the disease is to better 
emphasize the belief here expressed as to their identity, and 
also to follow a nomenclature which has long been familiar 
to English readers. As far as scientific accuracy is con- 
cerned, it would no doubt be better to call the disease fibrous 
and glandular hyperplasia with retention cysts, a term de- 
vised by Dr. W. F. Whitney, of Boston. The term abnormal 
involution, used by Dr. Warren, is also an appropriate one. 

As the process of cyst-formation advances and the cysts 
become larger, a stimulus to the proliferation of the epithelium 
within the affected ducts and acini is supplied, and in some 
cases this proliferation is so pronounced as to result in the 
formation of distinct papillary out-growths from the cyst-wall. 
It is this circumstance, no doubt, which has lead some to con- 
sider cysts presenting this appearance as true neoplasms. 
In addition to this form of proliferation Greenough and 
Hartwell have described what they call adenomatous prolifera- 
tion, a condition in which the papillary outgrowths coalesce, so 
that when a section of the tissue is examined under the micro- 
scope it appears as though there is a space filled with epithe- 
lium in which an occasional open gland can be detected. 



PLATE V. 




General cystic disease (abnormal involution). Microscopic appearances. 
Note the dilatations. 



Cysts 



73 



Warren has called attention to the fact that there may be 
an increase in the number of the acini in this disease, and 
that there is usually a marked associated proliferation of the 
epithelial cells in the ducts. 

In a certain proportion of cases of advanced cystic disease 
with proliferation of epithelium the morbid process may advance 
to malignancy. Greenough and Hartwell found associated 











Fig. 14. — Abnormal involution. Acinal type of epithelial proliferation. 

carcinoma in 10 percent of the cases which they studied and 
Warren found it in 13 percent of his series. 

In regard to the symptoms and signs of this disease, the 
remarks made under the description of chronic diffuse mastitis 
are applicable. As the cysts increase in size alterations in their 
contents, as well as changes in their wall often take place. 
Thus the fluid within them may become turbid or discolored, 
as is the case in single retention cyst. 

Treatment consists in removing all the diseased mammary 



74 Diseases of the Breast. 

tissue. In cases where a portion of the gland is comparatively 
free from disease I have of late practised plastic resection of the 
breast, according to the method of Warren, and find that it gives 
entirely satisfactory results. 

In these cases, however, I consider it of the utmost importance 
to have a competent microscopist present at the operation, so 
that a portion or portions of the diseased tissue may be examined 
at once with a view to determining whether any signs of car- 
cinomatous degeneration are present. If so, the breast is re- 
moved, together with the pectoral muscles and axillary glands. 
I consider it just as important to take this precaution in the 
class of cases now under discussion as in cases of tumors of 
doubtful nature. The extra time required for the microscopic 
examination is well repaid by the additional light which it 
may throw upon the character of the disease. In cases where 
the entire gland is riddled with cysts I invariably amputate 
the breast. 

Galactocele. 

By the term galactocele is understood a mammary cyst 
the contents of which is milk or some product of milk. In some 
such cysts the contents differs in no wise from the milk which 
is normally secreted by the breast during lactation, but in others 
it is thick and creamy or even caseous. Occasionally a caseous 
mass is found floating in milk-like or serous fluid. It is in 
recent galactoceles that the contents most closely resembles 
normal milk, whilst in those of long duration changes are apt 
to take place in the fluid which result in its assuming one of 
the characteristics just mentioned. Sometimes, too, the con- 
tents resembles colostrum. 

From these remarks it is seen that galactocele is an entirely 
different condition than engorgement of the breast with milk. 

This disease is one of the rarest to which the breast is subject. 
I have seen but a single case, and Keen, who states that he has 



PLATE VL 







^ ^ 




Fig. I. — Abnormal involution. Microscopic appearances. Papillary 
and adenomatous types of epithelial proliferation. (Warren.) 




:■ / 



^SK^^, 



Cxy**' 



,- V ■' 



^m^^ ^ 









v<-.=^s^= 






V^' 



F'iG. 2.— Abnormal involution and adenocarcinoma. IMicroscopic 
appearances. (IVarren.) 



Cysts. 77 

amputated five hundred breasts and seen three hundred others 
which were diseased, has hkewise seen only one case. 

Although galactocele most frequently develops during lacta- 
tion or just after the child is weaned, it may occur during 
pregnancy, and a few cases have also been observed in women 
who have never borne nor suckled children. My case was in a 
woman who had never been pregnant. 

It is usually stated that galactocele is a retention cyst, and 
while it is true that partial or complete occlusion of a milk-duct 
in the lactating breast, from whatever cause arising, would be 
likely to be followed by a retention of the secretion of the gland, 
the fact that galactocele occurs in women whose breasts have 
never secreted milk leads me to believe that the primary cause of 
the formation of these cysts is to be found in changes in the epi- 
thelial lining of the galactophorous ducts, as a result of which 
alterations take place that lead to dilatation of the ducts. 
Whether these changes in the activity of the epithelium lead to 
the formation of vegetations which partly occlude the duct, as 
is maintained by Labbe and Coyne, or whether dilatation occurs 
irrespective of obstruction, I will not presume to say. At all 
events endocanalicular changes afford a plausible explanation 
for the occurrence of those cases which have been observed in 
women whose breasts have never secreted milk. 

It would seem that traumatism is a factor of considerable 
importance in the production of galactocele, as a history of 
blows and other injuries to the breast has been given in a num- 
ber of the recorded cases. In some of these cases, however, 
the injury was received so long before the development of the 
galactocele that it is difficult to trace any causative relation 
between the two, unless it be assumed that the traumatism 
gave rise to alterations in the tissues which later, particularly 
during lactation, resulted in the formation of the galactocele. 
In this case it would be reasonable to assume either that the 
epithelium of the ducts had undergone alterations, or that as a 



78 Diseases of the Breast. 

result of inflammation in the interstitial tissue compression of 
the ducts had been effected, so that free outlet of the milk se- 
creted later could not take place. 

It is evident that the ideas here advanced concerning the 
etiology of galatocele are purely conjectural, and it must be 
admitted that the cause of this form of mammary cyst, in com- 
mon with the causes of many other affections to which the mam- 
mary gland is subject, are very obscure. Although little 
definite is known about them at present, it is to be hoped that 
further study will result in a better understanding of the manner 
of their production. 

In regard to the appearance of galatocele, it may be stated 
that it usually occurs as a single rounded swelling situated, 
as a rule, in the external segment of the breast. The size of 
the swelling is variable. At first it is small, but as time goes 
on it may attain a very large size. The average size is probably 
about that of a medium-sized orange. It is slow in develop- 
ing and may retain its original dimensions for a very long period 
of time. It has been observed that lactation causes a rapid in- 
crease in the size of the cyst. 

When the contents of a galactocelejs fluid fluctuation can 
usually be obtained, and pressure upon the swelling causes 
fluid to exude from the nipple. The latter circumstance shows 
that there is not complete occlusion of the duct. Galatocele 
is not painful and is not adherent to the skin nor to the 
parts beneath it. Its consistency naturally varies with the 
nature of its contents. A sign to which Gross called attention 
is pitting upon pressure. When this phenomenon is present 
it is probable that the contents is thick or caseous. Neither 
this sign nor fluctuation are always obtainable. Concerning 
the former Delbet states that in the absence of edema it is 
almost pathognomonic. 

Suppuration has been known to occur in a galactocele, and 
ulcerations have been found upon the internal surface of its 



Cysts. 79 

walls. In my case the breast was examined microscopically by 
Dr. McFarland, who found that the tissue surrounding the cysts 
was the site of a marked interstitial mastitis. Similar changes 
were found by Coplin and Ellis, who examined the breast in 
Dr. Keen's case. They state that the most conspicuous change 
was ^^a marked periacinous infiltration of mononuclear cells, 
nearly all of which were of the small round variety." 

In regard to diagnosis it may be stated that any fluctuating 
tumor developing suddenly in the breast of a woman who is 
nursing a child is probably a galactocele. Pitting upon pres- 
sure likewise is good evidence in favor of galactocele, as has 
already been stated. In other cases where the cyst has been of 
long duration or developed irrespective of lactation, diagnosis 
will not be so easy, and its nature may not be suspected until 
incision is made. 

The proper treatment of galactocele is enucleation of the 
cyst and excision of the surrounding tissue. Simple incision 
and evacuation of the contents is not satisfactory, as the sac 
is likely to fill up again. Puncture is mentioned solely to con- 
demn it. 

Hydatid Cysts. 

The mammary gland is occasionally though very rarely 
attacked by hydatid disease. In comparison with other dis- 
eases of the breast hydatid disease is of little importance on 
account of the rarity with which it occurs. In 1,897 cases of 
hydatid disease collected, from various sources by John D. 
Thomas only 20 affected the breast, an incidence of hardly 
more than i percent. When the rarity of hydatid disease itself 
is considered, the low percentage of the mammary form shows 
how rare it is in comparison with other affections of the breast. 

In regard to the etiology of mammary hydatid disease nothing 
positive is known. How the embryos of the parasite reach the 
mammary tissues cannot be positively stated, but it is probable 



8o Diseases of the Breast. 

that in the primary cases they gain access through the blood- 
stream. 

The breast may, however, be invaded secondarily from 
contiguous structures, notably from the great pectoral muscle. 

So far as I have been able to determine hydatid cyst of the 
breast has occurred only in women. It may affect any portion 
of the gland. 

Hydatid cyst of the breast begins as a small, hard, distinctly 
circumscribed swelling, which is freely movable on the parts 
subjacent to it. This swelling increases in size very slowly 
and may remain stationary for months or years. As a rule 
the cyst does not attain a very large size, probably not being 
any bigger than an orange in the majority of cases. In a case 
reported by Berard, however, it attained a volume twice as great 
as that of the other breast. 

It has been known to grow rapidly after injury. This hard, 
firm consistence is usually maintained after the cyst has become 
of a considerable size, although in some cases fluctuation has 
been detected. The latter phenomenon, however, has been 
observed only in large cysts. 

The wall of the cyst, which consists of two distinct layers^ 
is apt to become inflamed and suppurate, with the result that 
the cyst becomes adherent to the skin and finally breaks through 
it, discharging pus and the hydatid membranes and booklets. 
The axillary glands may also become enlarged. 

It is in these later stages, too, that the breast becomes pain- 
ful. It is common for these degenerative changes to take place 
in hydatid cysts of the breast the same as in those in other parts 
of the body. In twenty-four cases studied by R. G. LeConte 
the contents of the cyst showed changes from its normal limpid 
character in eight, or a percentage of thirty- three and a third. 

A very interesting case of hydatid cyst of the breast was 
operated on by Dr. LeConte, in 1899, at the Pennsylvania 
Hospital. It occurred in a young colored woman, aged twenty- 



Cysts. 8i 

seven years, who had spent all her life in Philadelphia and the 
neighboring city of Camden. The tumor was of four years' 
duration. For two years it remained of about the same size, 
but began to grow rapidly after an injury to the breast. From 
twelve to fifteen ounces of pus escaped when the mass was 
opened. This pus contained large numbers of hydatid hook- 
lets. 

LeConte believes this case to be the first one reported in 
America. A search through the literature failed to show any 
others reported in this country before or since. 

Diagnosis is very difiicult, as these cysts closely resemble 
benign growths as regards both consistency and size, as well 
as their manner of evolution. 

Suppurating hydatid may be mistaken for an abscess. 
Puncture of the cyst will reveal its nature, but this is likely to 
be practised only when suspicion exists that one is dealing with 
a hydatid. In most cases the diagnosis will be made only upon 
operation. 

Treatment consists in dissecting out the cyst when possible, 
or if it should be so large as to have destroyed much of the 
glandular substance, in partly or completely amputating the 
breast. Suppurating hydatid should be treated as an abscess. 

Dermoid Cysts. 

Dermoid cysts of the mammary gland are so rare that they 
require simply to be mentioned. There are very few cases 
recorded in literature. These cysts are, of course, always of 
congenital origin, although they may be so small as to escape 
detection until they suddenly begin to grow, perhaps late in 
life, and then first attract the attention of the patient. 

In addition to dermoid cysts in the substance of the gland, 
others originating from the sternum and encroaching upon the 
tissues of the breast have been reported. 

Diagnosis is difiicult and in the majority of cases will be made 



82 Diseases of the Breast. 

only at the time of operation. Treatment consists in excision 
of the cyst. 

Sebaceous Cysts. 

Sebaceous cysts are occasionally met with around the nipple, 
originating for the most part in the glands of Montgomery, 
although they may occur in any portion of the integument of 
the breast. They are usually small, but in some instances have 
been known to attain the size of an egg or even become larger. 
Increase in size, however, takes place slowly and the cysts may 
remain stationary for long periods of time. These cysts usually 
give rise to no S3niiptoms, being painless and non-sensitive to 
touch. They may, however, become inflamed. 

I recently removed one of these cysts from the breast of a 
young colored woman. She first noticed it about four months 
previous to the time of operation. It constantly increased in 
size, and for two weeks before operation had caused more or 
less dull aching pain, and occasionally sharp shooting pains. 
Treatment consists in dissecting the cyst out in its entirety, 
taking care not to rupture the sac. 



DIFFUSE HYPERTROPHY. 

This is a very rare affection in which the breasts increase 
abnormally in size either at puberty or during pregnancy. 
Its rarity is well shown by the fact that in 1902 Kirchheim was 
able to collect only forty-two authentic cases from literature. 

The disease has been carefully studied by this author and 
also by Schussler and Delbet, and it is from their works that 
much of the material for this article has been taken. The 
great rarity of the affection makes it necessary for a collective 
investigation to be made in order that any definite conclusions 
can be formed in regard to its nature, symptoms and course. 

In regard to the etiology of the disease, it may be stated that 
nothing is known other than that puberty and pregnancy exert 
a causative influence. Disturbances of the pelvic organs are 
often associated, but it cannot be logically maintained that they 
are causative. The mere circumstance that the menses fail to 
appear or suddenly become arrested, or the fact that ovarian 
enlargement exists simultaneously with the mammary disease, 
cannot be rightly construed to mean that the latter trouble is 
dependent upon the former. 

Among other conditions to which causative influence has 
from time to time been attributed may be mentioned irrita- 
tion, injury, cold, and celibacy. These, however, are to be 
considered as purely accidental conditions which have no 
bearing whatsoever upon the development of the disease. 

It has also been stated that race and climate are etiological 
factors, but the researches of Kirchheim tend to show that such 
is not the case. It is doubtful, too, as to w^hether heredity 
plays as important role, although Rousseau mentions the case 
of a woman whose sisters and nieces had exceedinglv large 

83 



84 Diseases of the Breast. 

breasts, and states that one of the sisters had an abnormal en- 
largement of the breasts during pregnancy. Pflanz also relates 
a case in which an uncle of the patient had abnormally large 
breasts. These data, however, are too meagre to permit the 
formation of any inferences. 

In regard to the morbid anatomy of this affection, it should 
first of all be stated that there seems to be a difference bet^veen 
those cases occurring at or about the time of puberty and those 
which develop during pregnancy. In the former class of cases 
the investigations of Labarraque, B artel, Schussler, and Kirch- 
heim seem to show that the morbid process is essentially a 
diffuse fibromatous overgrowth. In those occurring in preg- 
nancy there is a marked increase in the glandular elements. 
In one such case recently studied by Deibel glandular structure 
predominated. 

The subcutaneous fat over the breast frequently disappears, 
a circumstance which is probably due to the pressure exerted 
upon it by the new tissue. 

The symptoms as well as the morbid anatomy vary according 
as the disease develops in association with or irrespective of 
pregnancy. It has been observed that the onset is more sudden 
and the development more rapid in those cases occurring in 
pregnant women than in those occurring in the non-pregnant. 
Thus, for example, in a case reported by Delfis the breasts of a 
pregnant woman became so hypertrophied that they rested upon 
her thighs when she assumed the sitting posture, and this abnor- 
mal increase took place entirely during the period of gestation, 
the breasts before having been entirely normal. Esterle has 
reported another case in which they attained the weight of 
twenty-six to thirty pounds in three and one-half months. 

Two stages of the disease are usually described. In the first 
stage the norm^al contour of the breasts is preserved, the only 
change being an increase in their size. The skin is not altered, 
and the chief subjective symptom is uneasiness, or perhaps 



Diffuse Hypertrophy. 



8s 



slight interference with respiration, owing to the increased 
weight of the organs. Pain may or may not be present in this 
stage. Some authors state that it is absent, others that it is 
present. From a study of the Hterature it is found that the 
symptom occurs in some cases and is absent in others. 




-\ 



Fig. 15. — Diffuse hypertrophy. (Donati.) 

In the second stage changes take place in the form of the 
breasts, being due undoubtedly to the great increase in weight. 
They may become displaced from the pectoral muscles and 



86 Diseases of the Breast. 

fascia, to which they are only loosely attached. Alterations in 
the skin also occur. The. veins become distended and thicken- 
ing and edema are sometimes observed. Excoriations and ulcer- 
ations have also been known to develop, particularly where the 
skin is arranged in folds. In one advanced case mentioned by 
Marjolin there was a protrusion of glandular tissue through 
an ulceration. This case is unique. Whenever inflammation 
supervenes the axillary lymph-glands may become involved. 

As the breasts increase in size they become exceedingly 
burdensome and may greatly interfere with respiration, espe- 
cially when the patient is in the recumbent position. Pain in 
the ribs, palpitation of the heart, and distortion of the spinal 
column have also been observed. If the breasts encroach 
markedly upon the abdomen, digestive disturbances and con- 
stipation may be produced. A certain degree of cachexia 
supervenes in cases of long duration. 

The size attained by the breasts varies greatly. Thus in 
some cases they weighed not more than four or five pounds 
each, whereas in others their combined weight was found to 
be from twenty to sixty pounds. 

With the exception of those cases occurring in pregnancy 
the course of the disease is progressive. It may continue for 
many years. In an exceptional case reported by Donati, 
however, the condition remained stationary after about two 
months' progression. 

The cases associated with pregnancy are favorable, the 
breasts often returning to their normal size after the pregnancy 
is terminated. The course of gestation is not interfered with. 
Cases have been reported in which the disease developed a sec- 
ond time with the recurrence of pregnancy. 

In regard to treatment it may be stated that amputation of 
the breast is indicated in all cases other than those associated 
with pregnancy, provided that the hypertrophy is sufficient to 
produce disturbances of any consequence. The progressive 



Diffuse Hypertrophy. 87 

nature of the disease tends to make its treatment surgical. 
Beginning cases and those of slight degree have been treated by 
means of compression and the application of iodine ointment, 
but to me it seems irrational to expect much from such measures. 
As already stated the disease is essentially a diffuse fibroma. 
Therefore it is hardly probable that the above-mentioned meas- 
ures will exert much influence upon it. 

Amputation of the breasts, however, has always resulted in 
cure. Owing to the increased vascularity of the parts, trouble- 
some hemorrhage has been encountered, and for this reason 
it has been advised to transfix the organs at their base with long 
pins and then make compression by means of an elastic band 
passed around them. Amputation of the second breast has also 
been deferred until complete recovery took place from the first 
operation. 

Expectant treatment is indicated in the cases associated with 
pregnancy, for as already stated, the process undergoes resolu- 
tion after the period of gestation is passed. 



KELOID. 

This disease, which is in reahty an overgrowth of fibrous 
tissue beginning around the blood-vessels of the corium, 
is of importance when it affects the skin of the breast, as is 
not uncommonly the case, for the reason that it may be mis- 
taken for incipient or recurrent carcinoma. In the mind 
of a patient the so-called spontaneous keloid, first clearly defined 
by Alibert, often causes fear that she is the subject of mahgnant 
disease, and the secondary or cicatricial form, particularly if 
it develop on scars following incisions for malignant tumors, 
may give rise to apprehension that the disease is breaking out 
again, and thus worry both patient and physician until its true 
nature is determined. 

In regard to the etiology of keloid little is known. Formerly 
it was thought to develop solely in scars, but Alibert, as already 
stated, called attention to what he termed a primary or idio- 
pathic form of the disease, which he thought developed irre- 
spective of injury. Further investigations, however, have led 
to the conclusion, at least by most observers, that there is in- 
variably an antecedent injury, be it ever so slight, which sup- 
plies a basis for the development of the disease. Cases have 
been known to occur in which no history of the slightest trau- 
matism could be obtained, but if it be granted that a scratch 
or excoriation be sufficient, in those whose tissues are predis- 
posed, to set up a morbid increase of cells, the futility of relying 
on absence of a history of injury becomes at once apparent. I 
do not believe in the existence of idiopathic keloid. 

The disease has been observed superimposed upon the scars 
following burns of the mammary integument, furuncles, and 
those following the simple incision of abscesses, as well as those 

88 



Keloid. 89 

following more extensive injuries and operative procedures. 
Negroes are specially predisposed. 

Symptoms. — Keloid may be either single or multiple. It 
occurs as round, oval, or oblong nodules or plaques, of a white, 
pink, red, or purple color. Very frequently prolongations of the 
new fibrous tissue stretch outwards from the body of the growth, 
giving it a claw-like appearance. These growths increase in 
size very slowly and seldom produce any subjective symptoms. 
Occasionally, however, itching or pain is present. 

There should really be no difiiculty in diagnosticating keloid, 
although if the disease develops upon scars made in removing 
the breast for malignant disease, it may at first be mistaken 
for a recurrence. The peculiar character of the lesions, how- 
ever, should at once furnish an inkling as to their nature, which 
will be positively revealed as they progress. The so-called 
spontaneous keloid should offer no difficulty of diagnosis. The 
slow growth and the not uncommon claw-like projection, as 
well as the other characteristics above mentioned, should serve 
to distinguish it from scirrhus, provided, of course, that the 
existence of such a disease as keloid be borne in mind. 

As to prognosis it may be said that the disease is very rebel- 
lious to treatment, and that it persists for a long time. Spon- 
taneous diminution in size and even complete disappearance 
have been known to take place in cases which had resisted all 
therapeutic efforts. The disease is benign and does not endan- 
ger life; moreover, it seldom causes the patient any suffering. 

Treatment is not very satisfactory. Operation as practised 
in the past has been almost always followed by recurrence. 
If done at all the lines of incision should be carried far beyond 
the diseased area, so that an extensive removal of tissue may be 
effected. The wound should be skin-grafted instead of being 
sutured, as it has been demonstrated that recurrence often takes 
place at the site of the needle puncture. I am satisfied that 
the cases I have grafted did much better than those where 



90 Diseases of the Breast. 

suturing was practised, and the explanation would seem to lie 
in the avoidance of tension and sutures. 

I was led to make this suggestion many years ago, and an 
increased experience has only tended to confirm the opinion 
then expressed to the Louisville Surgical Society. 

Having seen excellent results follow the use of the X-rays, 
which undoubtedly cause some absorption of the growth and 
a more supple condition of the cicatrix, I am inclined to try 
this treatment in all cases before resorting to operation. Elec- 
trolysis has also seemed to cause a diminution in the size of the 
lesions in a few cases, but it more often has failed. 



TUMORS. 

Before taking up the specific tumors of the breast, it may not 
be amiss to devote a httle attention to tumors in general and the 
relation they bear to those in which we are most interested. 
The nature, origin and classification of tumors have long con- 
stituted a .much mooted question. Authors differ in their con- 
ceptions as to the nature and origin of the individual tumors, 
so that many definitions have been given. 
! The two predominating views held by oncologists as to the 
nature and origin of tumors in general are those of Virchow 
and Cohnheim. Virchow taught that tumors developed by 
metaplasia of adult tissue under proper stimulus or in the 
absence of proper restraint, placing practically no limitations 
upon its possibilities, claiming that connective tissue can 
be transformed into epithelium and vice versa. Cohnheim 
took diametrically the opposite view, referring every tumor- 
formation to the embryonal state, describing a tumor as a 
'^circumscribed, atypical production of tissue from a matrix of 
superabundant or erratic deposit of embryonal elements." 
He denies the possibility of metaplasia and refers every growth 
to the primary embryonic layers, portions of which, having 
been arrested at some stage of their development, have, under 
stimulus, taken on new growth and developed into tumors. 
Senn, in his work upon tumors, does not accept the Cohnheim 
view in its entirety, but claims, with Ribbert, that neoplasms 
may also be due to remnants or "anlage" of post-natal origin, 
giving as his definition of a tumor a "localized increase of 
tissue, the product of tissue proliferation of embryonic cells 
of congenital or post-natal origin, produced independently 
of microbic causes." 

91 



92 Diseases of the Breast. 

None of these views has been universally accepted, and it 
appears that they may all be used to explain the formation of 
different tumors and that none is the exclusive explanation 
of them all. The inclusion theory is undoubtedly the best 
explanation that has thus far been offered of the formation 
of the dermoid cysts and teratoid growths, which are almost 
invariably found in the center line and contain elements of 
misplaced epithelium in situations in which metaplasia cannot 
be considered. Again, it offers an excellent explanation for 
the neoplasms of the kidney composed of adrenal tissue (hyper- 
nephromata.) It might even be considered in many of the 
other tumors, as sarcoma, myxoma, angioma, enchondroma 
(in areas where cartilage is not a normal element), but that it 
cannot be offered in explanation of all the tumors appears 
evident from the examples that can so frequently be seen of 
direct metaplasia of normal structures into mahgnant growths. 
It is a well-recognized fact that carcinoma of the lip usually 
affects pipe smokers; that carcinoma of the tongue is fre- 
quently caused by a jagged tooth; that carcinoma of the 
uterus is most common in those who have borne children and 
have suffered laceration of the cervix; that carcinoma of the 
breast has a frequent antecedent history of injury; that mel- 
anotic sarcomata often follow injury to pigmented moles; that, 
in certain races, keloids often follow injury to any part of the 
body; that carcinoma of the stomach is most frequently found 
following history of ulcer, and in the pyloric region, and 
that carcinoma of the gall bladder is frequently found in 
conjunction with gall stones. The above examples might be 
multiplied, but they will suffice to illustrate the class of cases 
in which it is rather difficult to attribute the formation of the 
growths to the Cohnheim theory. It appears unlikely that 
these "anlage" should be deposited only in regions which are 
most subjected to injury. Finally, in some carcinomata of 
the breast, direct transition of normal acini into malignant 



Tumors. 93 

growths can be detected; likewise in certain fibromata, the 
direct metaplasia into malignant sarcomata can be seen by 
the microscope as well as corroborated by the clinical history. 

From the above, it appears most rational to attribute the 
origin of tumors to both sources, some as explained by the 
Cohnheim or even the Senn theory, and some to direct meta- 
plasia, as maintained by Virchow. Metaplasia undoubtedly 
does occur but not to the extent claimed by Virchow. One 
tissue may be transformed into a related tissue of similar epi- 
blastic, mesoblastic, or hypoblastic origin, but that a meso- 
blastic tissue becomes converted into a hypoblastic or epiblastic 
tissue, and vice versa, appears to me to be untenable. They 
are essentially different at birth and remain so until death. 
The apparent cases of mouse carcinoma becoming converted 
into sarcoma by transplantation are evidently due to the malig- 
nant metaplasia of the stroma of the growth, which has prolif- 
erated to such an extent as finally to overshadow the original 
epithelial growth and to appear as sarcoma. It is not an in- 
stance of direct metaplasia of epithelial tissue into sarcoma^ 
but a case of the survival of the most active element. 

In accordance with the above views, we may define a tumor 
as a newgrowth characterized by a histological diversity either 
of nature, amount, or arrangement of the cells, from the matrix 
in which it grows, having no beneficent functional activity 
and not microbic in origin. 

Tumors can be classified in various ways, either according 
to the conception of the tumors themselves or with reference 
to their chnical activities. 

From the pathological point of view tumors may be divided 
according to Ribbert as follows: — 



94 Diseases of the Breast. 

1 . Tumors of the Supporting Tissues (Connective Tissues) . 

a. Fibroma. 

b. Lipoma. 

c. Chondroma. 

d. Osteoma. 

e. Chordoma. 

f. Angioma. 

a, sarcoma. 
/3, osteosarcoma. 
7, chondrosarcoma, 
s, lymphosarcoma. 

g. Sarcoma. 

e, myxoma. 
r, chloroma. 
■n, myeloma. 
0, melanoma. 

2. Tumors of Muscular Tissue. 

Myoma. 

3. Tumors of Nervous Tissue. 

Neuroma. 
Ghoma. 

4. Tumors of Combined Epithelial and Connective 
Tissues. 

A. Fibro-epithelial tumors. 

a. Cutaneous. 

b. Originating in mucous membranes. 

c. Originating in glandular structures. 

B. Carcinomatous tumors. 

5. Chorionepithelioma. 

6. Endothelioma. 

7. Mixed Tumors, Embryoma, Teratoma, etc. 

This classification, which is based upon the histological 
appearances of the tumors, is far from ideal, but is probably 
the best for practical purposes, and especially when applied 



Tumors. 95 

to tumors of the breast. An ideal classification would be based 
upon the embryological basis alone, but this is difficult owing 
to the fact that whereas many of the tumors, especially of the 
fibro-epithelial variety, etc., are composed principally of epi- 
or hypo-blastic tissues, they contain a connective tissue stroma 
of mesoblastic origin. In addition combinations of almost all 
forms of tumors occur, some of which are of similar and others 
of different origin. 

It will be noticed that the classification does not include the 
infectious granulomata or cystic formations due to retention 
of normal secretions. These are not true neoplasms and 
should not be classed as tumors. 

While the above classification is most satisfactory from a 
pathological point of view, the division of the subject which 
is of most use to the surgeon is that which deals with the clinical 
behavior of the tumors. This is a very simple one, there 
being but two distinct classes, viz., benign and malignant. 
Benign tumors may be briefly defined as those growths, which 
per se exert no deleterious action upon the general economy, 
whereas malignant tumors may be defined as those growths 
which exhibit no signs of restraint, but progress to a fatal 
termination. Each has certain characteristics which distinguish 
it, and which, as a rule, should be recognized by the surgeon 
as soon as encountered, so that he should not always be 
compelled to depend upon the pathologist for a decision as 
to prognosis and treatment. 

Benign tumors are usually very slow in growth and distinctly 
localized, having a definite capsule. They rarely attain ex- 
cessive size, but occasionally, owing to their intrinsically benign 
character, may attain huge dimensions without injury to the 
general economy. Generally they are movable (unless bound 
down by surrounding inflammatory tissue or primarily attached 
to bone). They do not metastasize or become disseminated 
throughout the body, and when completely removed do not 



96 Diseases of the Breast. 

recur. They exert no influence whatever upon the general 
economy when favorably situated, but may endanger life by 
their size and situation when they interfere with the normal 
functions of any of the important organs of the body. They 
constitute the bulk of the tumors of youth, and need be removed 
only because of their size and location and because of the 
ever present danger of transformation into their correlated 
forms of malignant disease. 

Microscopically they can be distinguished by their non- 
infiltrating character, by their distinct encapsulation, by their 
tendency to conform to some definite type of normal adult 
tissue, and the absence of an actively growing edge with an 
abundance of cells showing karyokinetic figures. 

Malignant tumors exhibit diametrically opposite character- 
istics. They grow rapidly and usually diffusely. They are 
not encapsulated and may quickly attain considerable size, 
although huge malignant tumors are rather exceptional, since 
they usually prove fatal before they attain such proportions. 
They are intimately connected with the surrounding tissues 
and quickly become bound down and immovable. They 
metastasize and become disseminated rapidly through the 
lymph or vascular system, progressing steadily toward a fatal 
termination by the interference with vital functions caused by 
metastatic growths, or by an auto-intoxication which under- 
mines the general health and produces the condition commonly 
known as cachexia. 

Microscopically they can be distinguished by the embry- 
onal character of the cells constituting the growth and by their 
atypical structure, conforming to no definite adult normal 
tissue. They can be seen to be rapid in their growth by the 
abundance of cells undergoing indirect cell division. They 
are not encapsulated, but tend to invade surrounding struc- 
tures, blood and lymph channels, a circumstance which ex- 
plains their ready metastasis. 



Tumors. 97 

Each layer of the original ovum is represented by one ma- 
lignant tumor. The epi- and hypoblast are represented by 
the carcinomata and the mesoblast by the sarcomata. There 
are several types of each, but they are all related one to the 
other and all show some conformity to the above character- 
istics. All the other tumors are benign in nature. 

Before taking up the consideration of the tumors particu- 
larly common in the breast, a few words remain to be said 
with reference to the differences which distinguish the carci- 
nomata and the sarcomata. First and foremost is the char- 
acter of the cells which constitute the different growths. The 
sarcomata are composed of embryonal connective tissue 
cells, being either round (large and small), spindle (large 
and small), irregular in shape or polynuclear; whereas the 
carcinomata are usually larger, polygonal or columnar in 
shape and represent atypical forms of squamous or acinous 
types of tissue. The sarcomata grow with practically no 
stroma, the blood supply being from very thin-walled blood- 
vessels, which are in intimate contact with the tumor cells, 
by which they are frequently invaded. Carcinomata, on the 
other hand, frequently possess an abundant stroma between 
masses of cells, with a finer stroma between the individual cells, 
the cellular element encroaching upon the lymph channels of the 
surrounding tissue and the stroma of the tumor itself. Sar- 
coma advances with a solid growing edge, encroaching on the 
surrounding tissue as a whole, whereas carcinoma sends out 
finger-like projections through the lymph spaces, the new- 
growths increasing in size until they cause destruction of the 
tissue they have invaded. 

Sarcomata become disseminated, as a rule, by invading the 
vascular system, with the resulting transportation of emboli 
to distant organs, whereas carcinomata, while they may at 
times invade the system in a similar manner, usually do so 
by way of the lymphatic system, metastasis occurring first 

7 



98 Diseases of the Breast. 

in the nearest chain of lymphatic glands and trunks, from them 
to others more distant, and finally throughout the economy. 
As a result of these differences in methods of dissemination, 
sarcomata will recur locally after operation should the primary 
growth not be thoroughly removed, but otherwise at some far 
distant point; while carcinoma, perhaps when thoroughly re- 
moved at the site of the local growth, shows a tendency to 
recur, not locally, but in the nearest lymphatic structures, 
and only late in the disease shows general organic involve- 
ment. 

Finally, as a clinical difference of some value, but not so 
great as has been claimed in times gone by, is the difference 
in the age of the patients affected. It was formerly taught 
that carcinoma a was disease of old age (over 45) generally; 
but data are gradually accumulating which tend to convince 
us that we can never exclude the diagnosis of carcinoma 
merely on account of the youth of the patient, the \\Titer 
having obser\^ed many carcinomata in children, and carcino- 
mata of the breast have been noted as early as 19 years. The 
fact, nevertheless, remains that carcinoma occurs most fre- 
quently after forty (40) years of age. 

Sarcoma, on the other hand, is most frequently a growth of 
youth or middle age but here the reverse of the above is often 
found to be true, for sarcomata are found at all periods from 
infancy to old age. 

Concerning the benign tumors, little need be added to that 
already mentioned. The name given a tumor is in itself a 
description of the tissue of which it is composed, since benign 
tumors are more or less t}^ical of normal tissues although func- 
tionless and var}dng from the normal growth only in their situ- 
ations and the arrangement and comparative amounts of the 
various elements of which they are composed. In the tumors 
of mesoblastic structure, when composed of more than one kind 
of tissue, the name is usually made to include all the tissues 



Tumors. 



99 



comprised, beginning with the predominant one and going down- 
ward in the scale. In the benign hypo- 
and epiblastic tumors the same rule ap- 
plies, with the exception that themesoblastic 
element is not regarded unless present in 
excess of the amount required as a con- 
necting stroma for the epithelial tissues. 
They are, however, classified under the 
fibro-epithelial tumors. 

All that has been written above applies 
to tumors wherever situated, but it does not 
consider the relative frequency with which 
certain tumors are found in some regions 
and the peculiarities which they are liable 
to exhibit in various situations. Since the 
portion of the anatomy with which we are 
particularly interested is the breast, we can 
afford to devote our attention to it at once 
and leave the other organs to be treated in 
more general works. 

The breast is not prone to a great variety 
of tumors, although it is one of the most fre- 
quent sites in the body for some of them. 
While the whole subject of the etiology, etc., 
will be treated under the different tumors, 
it may be well to mention here that carci- 
noma constitutes more than three-fourths of 
all tumors of the breast and that the great 
bulk of the remainder are benign tumors of 
the fibro-epithelial type. While lipoma, 
angioma, chondroma, sarcoma, myxoma y^?- if— showing the 

^ -^ relative frequency of tu- 

and endothehoma do occur, they constitute mors of the breast; 

1 , T M 1 .•, T based on i^ooo cases col- 

an almost negligible quantity when com- lected from various hos- 
pared to the other two types of tumors. ^'^""^ '"^P'^'^'- 







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lOO 



Diseases of the Breast. 



The benign tumors of the breast have been so well^studied 
and classified by Warren, that I beheve the best scientific ends 



Percentage 
10 and 20 

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Fig. 17. — Showing the age incidence of benign tumors of the breast 
based on 1000 cases collected from various sources. 



will be served by adhering to his views almost in toto, at the same 
time contributing something to his effort at harmonizing and 
unifying the nomenclature used with reference to tumors of the 



Tumors. loi 

breast in general. He has struck the keynote of dissimilarity 
which exists between these benign tumors when he classifies 
them all together as fibro-epithelial tumors which exhibit some 
differences, owing to the disparity in the nature of the breast 
tissues in which they arise, and also to the fact that their growth 
is intimately associated with glandular epithelium which, in 
some instances, forces itself into prominence. 

These growths usually occur in young women, their greatest 
age incidence, as shown by the accompanying chart, being 
between the ages of twenty and thirty. 

Before proceeding with the individual growths I will give 
Warren's classification, filling in a few omissions made by him, 
in addition to giving the classification of the carcinomata which 
will be followed in this book. 

BENIGN TUMORS. 

Fibro-epithelial tumors 

(i) Fibrous type: 

Intracanalicular. 



1. Periductal fibroma ^ .^^ . ,. , 

[ Pericanalicular. 

2. Periductal myxoma. 

3. Periductal sarcoma (slightly malignant). 
(2) Epithelial type: 



I. 

2. 

Lipoma. 
Enchondroma. 


Fibro-cystadenoma. 
Papillary-cystadenoma 
Simple adenoma. 


Myxoma. 
Angioma. 
Endothelioma. 





I02 



Diseases of the Breast. 



MALIGNANT TUMORS. 



Sarcoma. 




I. 


Round cell. 


2. 


Spindle cell. 


3- 


Mixed cell. 


4. 


Giant cell. 


5- 


Alveolar. 


6. 


Melanotic. 


Carcinoma. 




I. 


Adeno-carcinoma. 


2. 


Medullary carcinoma. 


3- 


Carcinoma simplex. 


4. 


Scirrhus carcinoma. 


5- 


Carcinomatous cyst. 



FIBRO-EPITHELIAL TUMORS. 

By the term fibro-epithelial tumor, which was first used by 
Ribbert, is understood a growth of new formation containing 
both fibrous connective tissue and epithehum. 

Much confusion has existed in regard to the members of this 
group of tumors, owing to the diversity with which their 
constituent elements may appear, and likewise, though in les- 
ser degree perhaps, to the difference of opinion concerning 
their origin. It is principally concerning those new growths 
in which the one or the other of the above named tissues pre- 
dominated that the confusion has prevailed. 

Soon after the existence of benign tumors of the breast was 
recognized by Sir Astley Cooper and Cruveilhier the difficulty 
in classifying them began. There can be no doubt that the 
growth described by Cooper as chronic mammary tumor 
belonged to the class now under discussion, and that they were 
identical or similar to the ones described by Cruveilhier some 
years later as fibroma. Cruveilhier, however, maintained that 
the fibromata were quite different from those tumors which 
Cooper has described. He believed that they originated in the 
fibrous connective tissue of the breast, but his views met with 
much opposition, particularly in France, after the existence of 
benign mammary tumors became generally recognized. Addi- 
tional discord was lent to the subject by Lebert, w^ho, in 1850, 
made the first report of the microscopical study of these growths. 
I am quite in accord with Delbet, however, concerning the error 
which Lebert made, being convinced that his mistake consisted 
rather in the selection of an unfortunate term than in failure 
to recognize the true nature of the growths. Although he 
called these tumors partial hypertrophy of the breast, he stated 
clearly that in some the hypertrophy affected chiefly the librous 

10.^ 



I04 Diseases of the Breast. 

tissue, whereas in others its principal site was in the glandular 
elements. Despite the fact that he was attacked from all sides 
and his idea of partial hypertrophy subjected to ridicule, it is 
plainly manifest that the result of his observations constituted 
a decided advance in the knowledge of these tumors. Of 
course, a partial hypertrophy in the true sense of the word is 
impossible, but, as already stated, it is doubtful if Lebert in- 
tended to imply the existence of such a condition. 

The presence of both fibrous and epithelial tissue in the 
tumors was likewise recognized by Broca. 

Further investigation only served to increase the multiplicity 
of terms and lead to greater diversity of opinion in regard to the 
origin of the tumors. It was observed that cyst-formation 
took place in many of the growths, and that the stroma re- 
sembled sarcoma, hence the term cystosarcoma was applied 
to this form by Johannes Miiller. It was also noticed that 
the epithelium of the cysts sometimes proliferated, and so the 
term cystosarcoma proliferum was used to distinguish this va- 
riety from those in which no proliferation occurred, the latter 
being designated as cystosarcoma simplex. 

With few exceptions the members of the French school came 
to accept the belief that these tumors were of glandular origin, 
and thus the name adenoma was added to the list. To those 
tumors in which fissures and clefts were well-marked, as well 
as to those in which true cyst-formation occurred, the term 
cystadenoma was given. Papillary cystadenoma was also 
spoken of to designate those in which there was a papillary pro- 
liferation of the epithelium. Sir James Paget called this latter 
kind proliferous mammary cysts, and designated those in 
which cyst-formation does not occur as mammary glandu- 
lar tumors. 

Among other terms which have been used at various times 
may be mentioned adenocele, cystoid adenocele, cystoid 
glandular tumor, and cystic fibroma. 



Fibro-epithelial Tumors. 105 

Finally after the presence of both fibrous connective tissue 
and epithelium came to be universally recognized as essential to 
all, or at least nearly all of these tumors, and the instability 
of the mammary glandular epithelium came to be better under- 
stood, matters v^ere somewhat simplified by the adoption of the 
terms adenofibroma and fibroadenoma, according as one or 
the other constituent tissue predominated in a given growth. 

Cystic fibroadenoma or adenofibroma was applied to those 
in which cysts formed, and when marked proliferation of the 
epithelium took place papillary cystadenoma was spoken of. 

In his recent admirable paper on benign tumors of the 
b)reast,* Warren called attention to an important fact 
formerly pointed out by Billroth and also recognized by 
some of the French pathologists; namely, that the principal 
•constituent of those tumors more distinctly fibrous is the trans- 
parent periductal tissue of the mamma, which develops during 
puberty and lactation. Therefore he calls this type of tumor 
periductal fibroma, periductal sarcoma, and periductal 
myxoma, according to the character of the fibrous tissue pres- 
ent and the richness of cells. These forms constitute the 
fibrous type of fibro-epithelial tumors. 

The epithelial group, those in which the glandular element 
predominates and in which the epithelium is subject to marked 
changes, is composed of two members, according to Warren's 
classification, namely, the fibro-cystadenoma and the papillary 
cystadenoma. The former is the same as the cystic fibroma 
and the cystadenoma proliferum. The latter is identical with 
intracanalicular cystadenoma or the papillary cystoma. 

In addition to these two neoplasms I recognize and shall 
describe the simple adenoma, which I believe to be a definite 
pathological entity, though very rare. 

Etiology. — Various influences have been assumed to be caus- 
ative of the fibro-epithelial tumors, but if the eft'ect of injury 

^The Surgeon and the Pathologist; Jour. Am. Med. Ass., July 15, 1905. 



io6 



Diseases of the Breast. 



in the production of sarcoma be excluded, it remains to be 
proved that injury, heredity, pregnancy, lactation, or inflam- 
matory disease exert any causative influence. A possible 
exception may be made in regard to the papillary cystadenoma, 
in which the secondary proliferation of epithelium seems to 
depend in part, at least, upon the functional activity of the 
breast. 




Fig. i8. — Large periductal fibroma of right breast. 

Periductal Fibro^l\ (Fibroadenoma). 
These tumors occur in the breast as firm, round or ovoid, 
distinctly encapsulated bodies of varying size and consistency, 
as a rule being single, although they may be multiple. They 



PLATE VII. 




o 



Fibro-epithelial Tumors. 109 

are usually found in one breast only, but occasionally are pres- 
ent in both at the same time. Of slow development, they may 
remain of inconsiderable dimensions for a long period of time, 
or they may increase progressively in size from the beginning 
of their appearance in the mammary tissues. As ordinarily 
met with they are about as large as an English walnut or a 
small hen's egg, but I have seen them no larger than a cherry 
and then again as big as an orange. A few cases have been 
recorded in which these tumors attained extraordinary dimen- 
sions, some having been removed which weighed as much as 
six or seven pounds. In this era of modern surgery, however, 
such tumors are not likely to be encountered, for the reason that 
they will usually be subjected to the knife at a much earlier 
stage of their evolution. 

In regard to influences producing unwonted rapid growth 
in these tumors, it may be stated that some have been observed 
to increase suddenly in size during the menstrual periods, and 
that pregnancy in many instances exerts an undoubted stimu- 
lating effect upon their growth. It has been observed that 
tumors which had remained stationary for years suddenly 
began to grow after the occurrence of conception. This cir- 
cumstance in their natural history is of importance in reference 
to prognosis and treatment, and lends additional weight to the 
judiciousness of removing the growths, even though they give 
rise to only slight or perhaps not any symptoms. 

Symptoms. — The periductal fibromata are freely movable 
beneath the skin and are not attached to the deeper structures 
of the breast. Indeed, it is characteristic of them that they 
are superficial. As concerns their location the majority of them 
are found in the upper outer quadrant of the breast, but no part 
of the gland is immune. Neither retraction of the nipple nor 
lymphatic involvement occurs. As these tumors increase in 
size they become lobulated, and may thus impart an irregular, 
uneven feeling to the palpating finger as it is passed over their 



no Diseases of the Breast. 

surface. Their capsule is derived from the fibrous stroma of the 
breast. Both capsule and tumor move under the palpating finger. 

Considerable diversity of opinion has been expressed in 
regard to the subjective symptoms produced by these tumors, 
some authors stating they never give rise to pain, and others, 
as Gross, for instance, that they are painful in the majority of 
cases. Personally I have rarely known them to give rise to 
severe pain, although I have frequently had patients com- 
plain of a sense of uneasiness in the breast at and around 
the site of the tumor. In many cases this symptom was espe- 
ciallv noticeable durins; the catamenia. Labbe and Covne, 
and after them Gross, as well as many of the more recent French 
writers, stated that small tumors, no larger than a pea, fre- 
quently produce severe neuralgic pain, and considered them 
to be the underlying cause of many obscure cases of mastodynia. 
I have observed such a phenomenon in only a single case, 
and therefore consider it to be very rare, particularly as I 
have seen a large number of cases during the last twenty 
years. The case in question was that of a married woman, 
aged thirty-eight years, who complained of severe pain in the 
left breast, w^hich she had experienced in greater or less degree 
for seventeen years, the trouble dating from an inflammatory 
aft'ection requiring incision. Upon examination a small, hard 
tumor about the size of a cherry was found in the lower quad- 
rant of the breast. This growth was removed and after the 
wound healed the patient declared herself to be free from pain. 
I am of the opinion that this tumor, which proved to be a peri- 
ductal fibroma, was responsible for the subjective symptoms 
experienced. It evidently was of very slow growth, so that 
it was not detected for several years. 

Morbid Anatomy. — The appearance of these tumors upon 
section varies somewhat with the degree of their development. 
\Vhen still young the cut surface is white or rosaceous in color, 
whereas when older they are gray and have lost something of the 



Fibro-epithelial Tumors. iii 

glistening appearance which is characteristic of the younger 
growths. The Hne of demarcation between the capsule and 
the substance of the neoplasm is distinct. Bundles of fibrous 
tissue crossing one another in various directions can be plainly 
seen in the older growths. Microscopically they show both 
fibrous stroma and glandular elements in varying amounts. 






m.M^" -» ■.£^^^^^^&^'' 



Fig. 19. — Periductal fibroma. Microscopic appearances. {Warren.) 

In one form the fibrous tissue reaches a high state of activity, 
the epithelium showing little tendency to proliferate. As a 
result of this inequality of growth distortion occurs. Tumors 
of this type correspond to the intracanalicular fibroma. 

In another form both fibrous tissue and epithelium grow 
with an equal degree of rapidity, so that no distortion takes 
place. In a cross section of such a tumor the ducts are seen to 
be normally preserved. Tumors of this type correspond to the 
pericanalicular fibroma. 



112 Diseases of the Breast. 

Thus some are dense and compact, while others show clefts 
and dilatations. If the dilatation takes place rapidly the clefts 
are irregular, whereas if the process is slow they are at first some- 
what cylindrical in shape. The irregularity is due to compres- 
sion at various points by the increasing periductal fibrous tissue. 
Moreover, this growth of fibrous tissue enlarges the walls of 
the alveoli, and the epithelium which lines them becomes 
arched over the protuberances or invaginated into the depres- 
sions which are formed in the wall, so as to accommodate itself 
to the enlarged surface. Such enlargement and dilatation may 




Fig. 20.— Large periductal fibroma of the pericanalicular type. 

amount to cyst-formation, but as a rule the spaces are not large 
enough to be termed cysts. 

If secondary proliferation of the epithelium takes place, how- 
ever, it results in cyst-formation, and we then have to do with 
the fibro-cystadenoma. 

FiBRO-CYSTADENOA'IA (CySTIC AdENOAIA, PoLYCYSTO]VL4) . 

Chnically these growths dift'er little from large periductal 
fibromata, being firm in consistence, lobulated, and rarely 
giving rise to fluctuation. They are freely movable, painless, 
and do not cause enlargement of the axillary lymphatic glands. 



Fibro-epithelial Tumors. 113 

They commonly affect women of the same age as the simple 
periductal fibroma, although owing to the slow evolution of 
the latter growths the cystic changes sometimes do not occur 
until the tumor has existed a number of years. Gross observed 
that cystic changes in benign tumors of the breast were ordinar- 
ily found in those tumors removed from women between the 
age of thirty and forty, rather than in those between twenty 
and thirty. Although a portion of the tumors which he studied 








:^ ^-^ ^/^^ «^-'.-- ■■- 



Fig. 21. — Fibro-cystadenoma. Microscopic appearances. (Warren.) 

were papillary cystadenomata, which occur later in life than 
the other forms, others no doubt were fibroadenomata of 
slow evolution in which cystic changes had taken place at a 
late period of their existence. 

The contents of the cysts varies in color and consistency, 
being thin and clear in some and thick and opaque in others. 

Warren observed that the ducts appeared to be more involved 
in the tumors of this kind which he studied than were the alveoli. 

8 



114 Diseases of the Breast. 

The important thing to be remembered about this form of 
tumor is that it is really the same as the periductal fibroma 
except that a secondary proliferation of the epithelial elements 
has taken place. 

Papillary Cystadenojma. 

In this form of tumor still greater proliferation of epithelium 
occurs. The proliferation takes place in the form of wart- 
like excrescences, often pear-shaped, which protrude into the 
cavity of the cysts, sometimes almost completely filling the space 
within them. Not infrequently a number of branches are given 
off from a single one of these papillary structures. 

A multitude of names has been applied to this form of tumor, 
some of which have already been mentioned. In addition to 
intracanalicular cystadenoma and papillary cystoma, they 
have been called villous papilloma, duct papilloma and duct 
cancer. 

Warren has described these growths so accurately, both 
structurally and clinically, that I will quote from his article 
verbatim. 

"The histologic picture of a papillary or warty outgrowth 
is that of a connective tissue pedicle surmounted by an epithe- 
lial covering. Papillary structures of this character are the 
distinguishing feature of the tumors of this group and serve 
to differentiate them absolutely from other benign tumors of 
the breast. Tumors of this character rarely attain great size. 
Their consistency is hard, although fluctuation may occasion- 
ally be detected. Adherence to the skin and enlargement of 
the axillary glands are not to be expected. The situation of 
the tumor in the breast is generally beneath or in close relation 
to the nipple. The fluid contents of the cyst is generally 
hemorrhagic. Microscopic section shows the characteristic 
papillary outgrowths of connective tissue surmounted by a 
luxuriant growth of epithelium. The epithelium in these cases 



PLATE VIII 








n 



Papillary Cystadeuoma. Showing appearauce of the tumor when 
removed with contiguous tissues.— (JXmtrice If. Bichardson.) 



PLATE IX. 




O 






Fibro-Epithelial Tumors. 117 

presents the characteristics of ductal rather than acinal epithe- 
lial cells." 




Fig. 22. — Papillary cystadenoma. Microscopic appearances. Note exuber- 
ant growth of epithelium over papillary outgrowths of connective tissue from the 
wall of the cyst cavity. (Warren.) 

In twenty cases studied by Greenough and Simmons there 
was a history of trauma in five, no such history in seven. 



ii8 Diseases of the Breast. 

and no data could be obtained relative to the subject in the 
remaining eight. One case occurred in a man aged fifty- 
one. In Warren's cases the average incidence was fifty-two 
years. In the twenty studied by Greenough and Simmons it 
was forty-nine and one-half years. Thus it is seen that the dis- 
ease is most common in middle life. The youngest patient was 
nineteen, the oldest eighty-one, so that no age would seem to 
confer immunity. Of nineteen women eleven were married 
and eight had had children. Thus, there were eleven whose 
breasts had not undergone lactation, a circumstance which 
would tend to show that pregnancy and lactation are not pre- 
disposing causes. Warren, however, expressed the opinion 
that women who have borne and reared a number of children 
are particularly predisposed. 

These tumors are of slow growth, are only slightly if at all 
painful, and are usually situated just beneath the nipple. They 
are usually firm in consistency, although when large they may 
yield readily to the palpating finger, imparting a sense of elast- 
icity to it. The most characteristic symptom is said to be the 
discharge of bloody fluid from the nipple. This discharge 
may exist for a long time before a tumor is discovered in the 
breast, as was the case with three patients mentioned by Green- 
ough and Simmons. 

According to these authors the condition with which papil- 
lary cystadenoma is most likely to be confounded are cancer, 
abnormal involution and periductal tumors. 

From cancer they are to be differentiated by their slow 
growth, definite outline, and by the freedom of skin, muscles 
and axillary glands from involvement in the disease. 

From abnormal involution the diagnosis is more difficult. 
Serous discharge from the nipple in such cases is occasionally 
noted. The diffuse character of this condition, however, and 
the irregular nodular consistency of the breasts, associated 
with pain and tenderness are points that aid in differentiation. 



PLATE X. 



^' 




e 




Papillary cystadenoma. A. External appearance of the tumor. 
B. Interna] appearance. {Maurice H. Richardson.) 



Fibro-epithelial Tumors. 121 

Involution changes are also more common in the periphery of 
the breast, while papillary tumors occur almost invariably near 
the nipple. 

From periductal fibromata, the diagnosis should not be 
difficult. The periductal tumors occur, as a rule, at a much 
earlier age. They are firm and elastic, often of large size, 
and rarely occur near the nipple. They slip and slide in the 
breast tissue, and never produce discharge. The periductal 
fibromata are far more likely to be confused with the fibro- 
cystadenomata (the other type of the cystadenoma or epithelial 
group) and it is doubtful if the two can be distinguished with- 
out the aid of the gross and microscopic examination. (Annals 
of Surgery, February, 1907.) 

Simple Adenoma.* 

Simple adenoma is the rarest type of the fibro-epithelial 
tumors of the breast, Gross having observed only one in 115 
breast tumors, Billroth only one in 103, McFarland only one 
in a very large experience. This tumor must not be con- 
founded with the adenoma usually described in the text-books 
and monographs dealing with neoplasms of the breast, for they 
usually refer to the other forms of fibro-epithelial tumors. 

Simple adenoma is usually found as a definitely localized, 
soft, nodular growth occurring in young adult to middle age. 
It is not adherent to the skin but is intimately associated with 
the gland structure. It is freely movable over the underlying 
muscles. On section it is usually white or flesh colored, soft, 
and at times exudes a substance that resembles milk. It may 

* I have added this tumor to Warren's classification of benign growths. 
Since this article was written I have discussed the subject with Prof. Coplin, 
of Jefferson Medical College, who examined hundreds of sections from Gross's 
specimen. Prof. Coplin states that no other tissue but that of pure acinous 
type could be found. The same condition obtains relative to the growth 
shown in Plate XI. Of course the normal stroma of the gland is present. 



122 Diseases of the Breast. 

appear as one solid tumor or may be broken up into smaller 
nodules by thick septa of connective tissue. It is benign in its 
growth, not giving metastasis to the lymph glands or internal 
structures. 

Microscopically a simple adenoma is seen to be composed of 
numerous gland acini placed close together, separated by only 
a very delicate stroma of connective tissue. (See Plate XI.) The 
acini are usually lined with a single layer of cubical epithelium, 
but some may show proliferation of the epithelium until it en- 
croaches considerably upon the lumen of the- acinus. In these 
instances there is usually degeneration of the central cells with 
the formation of a material resembling milk. Scattered through- 
out the groups of acini are usually some ducts, which are 
commonly blind, although Gross considers the expulsion of 
milk from the nipple on pressure over the tumor as a diagnos- 
tic point of considerable value. If such is the case, some of 
the tubules must connect with the normal galactophorous ducts. 
The essential and differentiating points about this growth 
are the great preponderance of the glandular acini over the 
very small amount of stroma and the fact that the epithelium 
lining the acini is strictly confined by the membrana propria. 
It exhibits no tendency to cyst-formation, infiltration or atyp- 
ical epithelial proliferation. Should any portion of the tumor 
become infiltrating in character, it should no longer be con- 
sidered an adenoma, but be immediately placed among the 
adeno-carcinomata . 

Prognosis. — In regard to the prognosis of the fibro-epithelial 
tumors, it may be stated that all are benign growths, which do 
not recur after complete removal. The cases in which recur- 
rence has been supposed to take place are those in which rem- 
nants of the tumor were left behind, or in which growths so small 
as to escape notice at the time of operation later developed and 
thus lead to the belief that the original tumor had grown again. 
The papillary cystadenoma may undergo malignant changes. 



PLATE XI. 








'*•. 
















Simple adenoma. Microscopic appearance. {Drazcmg made from a specimen 
loaned by Dr. George P. Miiller, of the University of Peimsyh-ania.) 



Fibro-epithelial Tumors. 125 

In three out of twenty cases recently analyzed by Greenough 
and Simmons, associated carcinoma was found, cancerous 
nodules being present in the cyst- wall. It is stated that except 
for the infiltration of surrounding tissues, the nodules presented 
characteristics of growth of the same general character as the 
papillary structures within the cyst. The irregular cell growth 
and the infiltration, however, left no doubt about the diag- 
nosis of adenocarcinoma. (Annals of Surgery, February, 
1907.) 

The duration of these cancer cases was nine, twelve and 
eighteen months respectively, and their ages were fifty- two, 
sixty-nine and seventy-six years. 

The axillary glands were not palpably enlarged in any of 
these cases, and in two in which the axilla was cleared out 
no evidences of disease were found. 

In two of the patients no evidences of recurrence were found 
at the expiration of one and two years. The third patient, 
however, died of recurrence four years after the operation. 
With early and complete removal, however, the prognosis 
of this group of tumors is favorable. 

Treatment of the fibro-epithelial tumors is purely surgical 
and consists in extirpation of the growth. 

It is irrational to employ such local measures as the applic- 
ation of iodine or mercurial ointment with the expectation 
that they will even in the slightest degree produce retrogres- 
sive changes in the tumor. Their effect is nil. Spontaneous 
retrogression is not to be counted upon. I do not recall a 
single instance in which it has taken place. 

Small growths superficially situated may be excised un- 
der cocaine. For others I prefer the plastic resection of the 
breast as elaborated by Warren. It not only obviates the 
necessity of inflicting an unsightly scar, but, moreover, enables 
the surgeon to inspect the entire breast, and thus detect the 
presence of small tumors which may be present and which 



126 Diseases of the Breast. 

could not be located if simple excision of the principal growth 
were practised. 

The operation of plastic resection, first suggested by T. 
Gailliard Thomas and recently elaborated by Warren, is per- 
formed as follows: The preliminary incision is begun at the 
lower border of the breast, opposite the middle of the outer 
arc of the lower inner quadrant, and runs along the lower fold 
and outer margin to the inner border of the axilla, thus sever- 
ing the lymphatic connections of the breast with the axillary 
plexus of lymph glands. The incision should be carried down 
to the lower border of the pectoralis major muscle, which should 
be freely exposed. The dissection is then carried along through 
the loose connective tissue, which lies between the pectoral 
fascia and the posterior layer of the fascia in which the mammary 
gland is contained. With the left hand the operator reflects the 
breast upward and inward, so that the posterior surface becomes 
exposed in its entire length. The gland tissue can now be seen 
through transparent fascia and easily inspected, and any cysts 
present readily seen. Usually one or two lie in the same quad- 
rant, which can be removed by a V-shaped incision, without 
opening the cysts. The apex of the V lies directly under the 
nipple in the center of the gland. Radiating from this point 
incisions can be carried into the gland tissue in all directions, 
exposing and bisecting all small cysts so that none remain 
which have not been laid open. A second V-shaped incision 
may occasionally be necessary, but this is rarely the case. The 
next step after arresting hemorrhage is to close the V incision 
with two rows of catgut sutures, one along the anterior border 
and one bringing the posterior edges into contact. The gland 
is then dropped back on the pectoral muscle, and it will be 
found that the various incised portions resume their natural 
position and fit accurately together. The gland is then anchored 
to the pectoralis major muscle at the outer edge. Another 
row of sutures is advisable to hold together the deep layers of 



Fibro-epithelial Tumors. 127 

the superficial fascia before the outer edges of the wound are 
closed with silk- worm gut. The buried sutures remove tension 
from the surface sutures. The dressing is so applied as to 
produce lateral compression of the two hemispheres of the 
breast. 

It has been stated that this operation endangers the nutri- 
tion of the gland by interfering with its blood supply, but 
this statement is based upon an erroneous conception of the 
manner in which the blood-vessels of the breast are arranged. 
By referring to the section on anatomy it will be seen that the 
anterior surface and portion of the gland receive the principal 
arterial and venous channels, and not the posterior, which is 
the one chiefly involved by the incisions. I have done this 
operation twenty times and find it satisfactory in every respect. 
In all these cases the wound healed by primary intention. 



PLATE XII. 







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PLATE XVIII. 




Showing the appearance of the breast after extensive removal of tissue 
for multiple cysts in the operation of plastic resection. Notice the 
slight degree of deformity. 



PLATE XIX 




Showing appearance of'the breast after plastic resection. 



PLATE XX. 





Showing absence of scar and deformity after removal of a benign growth from 
the left breast by the operation of plastic resection. 



LIPOMA. 

Lipomata of the mammary gland are rare, although they oc- 
casionally occur; they may develop in the gland itself or grow 
either in the subcutaneous tissue or in the retromammary 
region. When we come to consider the abundant supply of 
fat in the breast the question naturally arises why lipomata 
are not more common in and about this organ, and it seems to 
me to be peculiar that they are not more often met with. 

In regard to their etiology little or nothing is known. They 
develop in the breast without any apparent cause. A certain 
causative influence has been attributed to injury in a few cases, 
but it is doubtful whether the relation between the traumat- 
ism and development of the tumor was one of cause and 
effect. 

These tumors may be either single or multiple, and may 
vary much in size. Usually when the patient comes to opera- 
tion the tumor is not larger than an orange, although in litera- 
ture cases are recorded in which growths of enormous size 
have been removed. In one of Sir Astley Cooper's cases the 
tumor weighed over fourteen pounds. It has been observed 
that pregnancy stimulates them to active growth. The sub- 
cutaneous variety is probably the most common, although a 
number of cases of the retromammary form have been recorded. 
The former are always encapsulated by a thin fibrous mem- 
brane which sends septa down into the substance of the tumor. 
Their development is slow. In a case reported by Delage and 
Massabiau the tumor attained the size of an orange in seven 
years. They are not sensitive to pressure, but are frequently 
painful, and if of large size may cause discoloration of the 
skin owing to the congestion which they produce by pressure. 

147 



148 Diseases of the Breast. 

There is no invoh^ement of the axillary glands and no tendency 
to encroachment upon the surrounding tissues. The tumor, 
as already stated, is encapsulated, and therefore well-defined, 
unless it be of large proprotions so that it practically obliter- 
ates the gland. Multiple tumors of small or moderate dimen- 
sions give the breast an uneven, bosselated appearance. 

It is characteristic of subcutaneous lipomata that they roll 
readily between the thumb and fingers, and that they are not 
hard to the touch. Indeed they have been mistaken for cystic 
tumors and galactocele with caseous contents. Moreover, 
they are, when arising near the axilla, frequently symmetrical, 
tumors of equal size and shape, being found on either side. 
They also are frequently pedunculated. 

Retromammary lipomata develop between the gland and 
the great pectoral muscle, and as they increase in size displace 
the breast, pushing it forward or to one side, according to 
their site and the direction in which they grow. They may 
attain a large size and cause congestion and discoloration of 
the skin over the breast exactly as do large subcutaneous tumors. 

Intraglandular lipoma is very rare, and only a few observa- 
tions have been recorded. In this form of the tumor micro- 
scopic examination reveals the presence of galactophorous ducts 
traversing the substance of the growth. In a case operated 
on by Demons some of the ducts within the tumor were con- 
siderably dilated and filled with a thick yellow substance re- 
sembling coagulated milk. Others were somewhat atrophied, 
their lumen appearing like a transparent point in the surround- 
ing tissue. In some the epithelium was preserved in its normal 
condition, but in others it was found to have undergone altera- 
tions. 

In a case recently reported by Delage and Massabiau evi- 
dences of myxomatous degeneration were observed in the 
tumor. 

An interesting case of a lipoma containing cartilage has 



Lipoma. ^ 149 

been reported by Sick, of Hamburg. The tumor was removed 
from, the breast of a woman aged seventy- two years. It 
was made up of firm, pure lipomatous tissue, throughout which 
were interspersed small areas of hyaline cartilage surrounded 
by a zone of fibrous tissue. 

Lipomata are essentially benign tumors, yet their removal 
is always indicated. Single or small multiple subcutaneous 
growths may be excised. For the removal of retromammary 
and intraglandular growths I advise plastic resection of the 
breast, unless the tumor or tumors are so extensive as to com- 
pletely destroy the gland, in which case amputation is the 
proper measure to employ. 



ENCHONDROMA. 

Although tumors containing cartilage or composed entirely 
thereof are not uncommon in the breasts of certain animals, 
particularly bitches and she-goats, they are rarely found in the 
human breast, and when they do occur it is usually in com- 
bination with other tissues rather than as pure cartilaginous 
growths. Thus chondrosarcoma, chondromyxoma and even 
chondrocarcinoma are more frequently met with than pure 
enchondroma or chondro-osteoma. 

Instances of invasion of the breast by cartilaginous tumors 
originating from the costal cartilages have been recorded, 
but such mammary involveinent is merely a secondary change, 
and is not to be considered with the intrinsic neoplasms of the 
gland. 

While some cases which have been recorded as enchondroma 
of the breast were undoubtedly mixed cartilaginous tumors, 
that is, sarcomatous or myxomatous growths containing car- 
tilage, pure chondromatous and osteo-chondromatous growths 
certainly may occur. Thus, for example. Sir Astley Cooper 
removed a tumor which was undoubtedly a pure enchondroma, 
and Burck removed a breast containing an osteo-chondroma 
as large as a man's fist. 

This tumor, which was carefully examined by Edmund 
Leser, who reported the case, was taken from a woman aged 
sixty-seven years. It was first noticed sixteen years prior to 
the time of its removal, being no larger than a hazel-nut. There 
was no known cause for its development. It was oval in shape, 
encapsulated, firm, and resistant to the knife. The cut sur- 
face was gray in color. In the interior of the growth there was 
a bone-like nodule so hard that it could not be cut except with a 
saw. 

150 



Enchondroma. 151 

In another case, that of a patient operated upon by Mazzu- 
cheUi, the tumor had existed even longer than in the above 
case, having been present twenty-five years. During this 
time it had attained the size of an egg, and gave rise to pain 
only six months before it was removed. This tumor was also 
hard, firm, and gray in color. The cut surface was shiny, and 
in the center there was a softened area. 

Microscopic examination of both these tumors showed them 
to be composed of cartilage cells. 

These two cases well illustrate the slow growth of enchon- 
dromatous mammary tumors, and the absence of symptoms 
arising from their presence. 

In regard to the etiology of these tumors, it is probable that 
they are of heterotopic origin, although the theory that the 
cartilage develops from the fibrous tissue of the breast has been 
advanced by different investigators. It has been suggested 
again only recently by Cornil and Petit, who base their belief 
upon the circumstance that they found the connective tissue to 
have various modalities, such as , the myxomatous, chronic 
inflammatory and pseudo-sarcomatous ; and also upon the 
fact that they found remains of mammary tissue in ossified 
portions of the tumors which they examined. I must confess, 
however, that I find it difiicult to relinquish the idea that tissue 
is generated from tissue of its own kind, and therefore hold 
to the inclusion theory. 

It seems convenient to consider in this place the mixed 
tumors containing cartilage. 

As already stated, such tumors are met with more frequently 
than pure enchondromata. The cartilage varies in quan- 
tity, in one being contained only in small amounts, whereas 
in others it constitutes the greater portion of the tumor. 

In chondrosarcoma the cartilage may form well-defined 
trabeculae. 

These mixed tumors vary in size, some being small and 



152 Diseases of the Breast. 

others large. In Dubar's case of chondromyxoma the breast 
was as large as a child's head, and the skin had ulcerated. 

A very interesting case of mixed cartilaginous tumor has 
been recently reported by Salomoni. The tumor was oval in 
shape, as large as a baby's head, and was well-defined from 
the skin, the great pectoral muscle, and the surrounding mam- 
mary tissue. 

A small cyst containing dark viscous fluid was present in 
the substance of the growth. 

Upon microscopic examination the tumor was found to be 
made up of a stroma of fibrous connective tissue arranged in 
parallel bundles, containing oval and round cells in the meshes 
of the stroma and in the cavities. In the older portions of the 
tumor myxomatous degeneration was detected, and zones of 
fibro-cartilage were interspersed throughout the section. I 
incline to the belief that all such mixed tumors are prone to 
become malignant, if indeed they do not actually represent 
malignant growths from their very beginning. For this reason 
I advise amputation of the breast as the proper method of 
treatment. So, too, whenever simple cartilaginous tumors are 
diagnosticated or suspected I would advise removal of the 
breast. As already stated, I believe them to be of heterotopic 
origin and consider them likely to assume malignant propen- 
sities. Enchondromata, wherever situated, are dangerous neo- 
plasms and they are even more prone in the breast than else- 
where to undergo malignant transformation. 



MYXOMA. 

This is a very rare growth and, indeed, its existence as a 
primary neoplasm has been questioned, it having been as- 
serted that the myxomatous tissue was due to degenerative 
changes in other growths. 

A few cases have been reported, however, which seem to 
show that myxoma may exist in the breast as a primary growth. 

A good example of such a case has been recently reported 
by Clement. It was that of a woman, aged fifty-nine, who pre- 
sented a voluminous pedunculated tumor of the left breast, 
which extended downwards to the abdomen, and which had an 
extensive area of suppuration upon its lower extremity. The 
skin over the remaining portion of the breast was much dis- 
colored and the nipple had almost disappeared. Upon palpa- 
tion the tumor was found to be soft, fluctuating and uneven. 
There was no axillary involvement, although the tumor was 
of three years' duration. It had been painful, however, from 
the beginning. 

A diagnosis of ulcerating cystic sarcoma was made and 
the breast removed. 

The tumor was found to be encapsulated, was gelatinous 
upon section, and showed vascular striations. 

Upon microscopic examination it was found to be composed 
essentially of mucous tissue. There were also fibromatous 
and hemorrhagic areas. The normal elements of the gland 
had nearly all disappeared. 

This case was evidently one of pure myxoma, as the tumor 
was of too brief existence for such extensive myxomatous de- 
generation of a fibroma to have taken place. 

Such instances as this are to be considered as borderland 

153 



154 Diseases of the Breast. 

cases between benign and malignant neoplasms. Myxomat- 
ous tissue, as is well-loiown, is the lowest type of adult tissue, 
and its existence as a primary mammary neoplasm, of which it 
makes up the essential constituent element, seems to me to rep- 
resent the connecting link between fibroma and sarcoma. 

This view is corroborated by the circumstance that myx- 
omatous degeneration of benign tumors is often associated with, 
or followed by, sarcomatous changes. Clinically the rapid 
growth and not uncommon occurrence of such tumors after 
removal lends support to this view. It must not be forgotten, 
however, that sarcoma may undergo myxomatous degeneration 
exactly as fibroma does. 

In regard to the origin of the myxomatous tissue, it may 
be stated that it develops in the periductal connective tissue. 
When secondary it probably is produced as the result of edema 
in this tissue (Warren). 

Myxomatous tumors vary in size, some being no larger 
than a hen's egg, while others are as big as a cocoanut. They 
are encapsulated and lobulated, and vary in consistence, some 
being soft or fluctuating and others hard and firm. The 
axillary glands are sometimes involved. Occasionally cysts 
are found in the substance of the tumor, particularly in those in 
which the myxomatous process is the result of secondary de- 
generation. 

Treatment consists in amputating the breast, and also clear- 
ing out the axilla, if there is any glandular involvement. Re- 
currence is not so apt to take place as it is in sarcoma. 



ANGIOMA. 

Angioma may affect not' only the integument of the breast 
and the subcutaneous tissue, but may also occur as a primary 
growth in the substance of the gland itself. Although Klebs 
asserted that involvement of the gland proper was always sec- 
ondary, being caused by extension of the growth from super- 
jacent structures, several cases of undoubted authenticity have 
been reported in which the tumor originated in the breast itself. 

In regard to the etiology of mammary angioma, it may be 
stated that the tumor is always present at birth or makes its 
appearance during the first weeks or months of life. Sex ap- 
pears to be entirely without causative influence. Cases have 
been observed at all periods of life from infancy to old age. 
Thus it is seen that the tumor may remain of insignificant di- 
mensions for a long time and then after the lapse of years sud- 
denly begin to develop. In a number of cases, however, it in- 
creased constantly, though slowly, from birth, so that it attained 
a considerable size during the early years of childhood. In 
Althorp's case the affected breast had become very much en- 
larged at the seventh year of life, and in one reported by Bajardi 
a child two years of age presented a tumor of the right breast 
as large as a mandarine. 

Following injury these tumors not uncommonly begin to 
grow rapidly, so that one which has been no larger than a 
walnut for years may become as large as an orange within a 
few months. 

Morbid Anatomy.— Angioma of the mammary gland devel- 
ops in the fibrous stroma and interlobular fat. The growth is 
riddled with cavities varying much in size and containing 
blood, which may be either liquid or inspissated. Some may 
be as large as a marble while others are no bigger than the head 

155 



156 Diseases of the Breast. 

of a pin. These cavities may be either round or irregular 
in shape, and are separated from one another by fibrous or fibro- 
muscular septa. Pressure of the tumor upon the glandular 
structure causes atrophy of the latter, so that in cases in which 
the entire breast is affected there may not be a vestige of the 
acini and ducts left. ^Vhen the tumor occupies only a portion 
of the gland, however, normal elements are present in the 
parts not affected. 

As a rule angiomata are not encapsulated, although in Ba- 
jardi's case there was a distinct fibrous envelope around the 
tumor, from which the fibrous septa between the cavernous 
spaces within the growth were evidently derived. 

Cysts may also form in angiomata and probably represent 
degenerative changes. iVt least this is the view put forth by 
Malapert and Morichau-Beauchant, in whose case there were 
three distinct, separate cysts contained within the tumor, 
and is one with which I readily agree. The cysts may contain 
serous or sanguinolent fluid. 

When examined microscopically the vascular spaces are 
seen to be filled with red blood-corpuscles. There is also an 
infiltration of leucocytes at the periphery of the septa dividing 
the spaces one from another. Between the different spaces a 
collection of fat-corpuscles may be seen, and areas of hemor- 
rhage can sometimes be detected in the interstitial and fatty 
portions of the growth. In a case carefully studied by Mala- 
pert and Morichau-Beauchant the acini in parts of the gland 
close to, but not invaded by, the tumor were found to be in- 
flamed. There was a decided proliferation of the epithelium, 
and some of the acini were completely filled with new cells. 
In the same case sections, of the cyst-wall were examined, and 
it was found to consist of two distinct layers. Blood-vessels 
were very numerous. The external layer of the wall was in- 
filtrated with cells resembling lymph cells, being round and pre- 
senting a single large nucleus, which stained readily with hema- 



PLATE XXI. 




Angioma. (Sick.) 



Angioma. 159 

toxylin. These cells were placed one upon another without any 
intervening tissue, so that in certain places they appeared 
like minute nodules. In the interior of some of these masses 
cavity formation had already begun. 

In Sick's case the tumor consisted chiefly of connective 
tissue poor in cells with little masses of fat interspersed through- 
out its substance. The ducts were greatly dilated and lined 
by a single layer of cylindrical epithelium. Veins and arteries 
having normal walls were exceedingly numerous. At certain 
places they were surrounded by leucocytes. Besides these 
vessels there were many large spaces filled with blood-corpus- 
cles. A few of these dilatations had a wall composed of muscle 
fibers and connective tissue, whereas others showed merely 
an epithelial lining. (See Plate XXI.) 

Symptoms. — Angioma appears in the breast as a soft, elastic 
tumor, which is painless and not sensitive to pressure. It 
frequently pulsates and often becomes reduced in size under 
pressure, although it resumes its former dimensions when the 
pressure is removed. The gland is freely movable and the 
skin over it is not adherent. Not uncommonly there is a 
dilatation of the cutaneous veins. In Bland Sutton's case the 
skin became invaded by new growth and ulceration occurred, 
which gave rise to some hemorrhage. Discoloration of the 
skin has also been observed. 

Violent exertion, straining and crying have been observed 
to cause enlargement of the growth. The effect of trauma 
has already been mentioned. 

If cysts are present they may make the surface of the tumor 
rough and uneven and may give rise to fluctuation. Under 
these latter conditions it is evident that diagnosis may be ex- 
tremely difficult. 

The treatment of mammary angioma consists in complete 
removal of the breast. In cases of areolar or subcutaneous 
angioma excision of the diseased tissue may be practised. 



ENDOTHELIOMA. 

Among the tumors but rarely found in the breast, although 
comparatively common in the salivary glands, is endothelioma. 
The only case of which the writer has any knowledge is that 
reported by J. Chalmers DaCosta, in 1903, the pathological re- 
port upon which was made by W. M. L. Coplin. This tumor 
was found in a woman 31 years of age who had borne one child 
ten years previously. The tumor was 10 cm. in diameter and 
had been noticed three months previous to operation. It was 
not accompanied by any discharge from the nipple and caused 
a dull ache only one month prior to its removal. It was located 
near the nipple, the skin being healthy and movable over it. 
There was slight retraction of the nipple which was more ap- 
parent than real. The axillary glands were not enlarged. 
Incision into the growth was accompanied by more than the 
usual amount of hemorrhage. 

Microscopically it was characterized by the formation of 
large spaces with no definite walls, but filled with closely packed 
round or oblong cells of various sizes, having small, deeply 
staining basophilic nuclei and granular cytoplasm. Some of 
the spaces contained blood in addition to that contained in the 
rather vascular stroma. The tumor was not encapsulated. 

Prognosis. — Owing to the extreme rarity of this form of 
growth it is difficult to make any definite statement upon this 
point. Considering its behavior in other organs, however, we 
may, by analogy, say that total extirpation should be followed 
by absolute cure, but that rapid recurrence with increasing 
tendency to malignancy is almost certain should removal be 
incomplete. 

160 



SARCOMA. 

Sarcoma is one of the rarest neoplasms which affects the 
mammary gland, and is not even so common as the older sur- 
geons, who stated that it comprised from five to nine percent 
of mammary tumors, believed it to be. No doubt the higher 
percentages formerly considered as correct are attributable to 
faulty nomenclature; for as in the case of the benign tumors 
of the breast, so likewise as regards sarcoma, there has been an 
inaccuracy in the use of terms employed to designate these 
growths. As an illustration of this error, it will suffice to men- 
tion that even Tillmanns, in the last edition of his excellent 
treatise on surgery (Lehrbuch der Allgemeinen und speciellen 
Chirurgie, Leipzig, 1904) speaks of cystosarcoma phyllodes in 
his article on sarcoma of the breast. This tumor, as I have 
already stated, is in reality the papillary cystadenoma, it being 
the name applied to this growth many years ago by Johannes 
Mliller. 

In this connection it is noteworthy that Finsterer's statistics, 
based on the cases which came under observation in Hochen- 
egg's clinic in Vienna during the last twenty years, give a per- 
centage of six if cystosarcoma phyllodes be included, but that 
the percentage falls to three if the latter be excluded. 

No doubt a similar distinction would decrease the percent- 
age in other series of cases. 

Still another way in which an erroneous idea as to the 
frequency of sarcoma may have gained ground is in mistaking 
benign cystic tumors, particularly papillary cystadenomata, for 
cystic sarcomata. 

W. Roger Williams, who collated 2397 cases of tumor of the 
breast, found that ninety-four, or 3.9 percent were sarcomata. 
My own statistics, based upon a still larger number of cases, 
II 161 



i62 Diseases of the Breast. 

show even a lower percentage. Thus, of 5000 cases of tumor 
of the breast which were collected from entirely trustworthy 
sources, only 2.78 percent were sarcomata. As further illus- 
trating the rarity of this disease I may mention incidentally 
that when studying the age incidence of mammary sarcoma I 
was able to collect only one hundred cases reported in recent 
years in which the age of the patient was stated. Not more 
than one-half dozen cases in which the age of the patient was 
not stated were found. My material included the cases which 
have occurred in nearly all the large London hospitals during 
the last fifteen years, or at least all those which appeared in the 
official reports of these institutions. In a recent analysis of 
628 cases of malignant tumor of the breast Sick, of Hamburg, 
found that only 12, or 1.9 percent were sarcomata. 

The late S. W. Gross based his classic paper on sarcoma of 
the breast on one hundred and fifty-six cases, which was all 
that he could collect after a most exhaustive search through the 
literature. He, however, considered the disease to be much 
more frequent than later statistics show it to be. 

Williams has also pointed out that the relative liability of 
the female breast to sarcoma is considerably below the average 
for the body in general, 9.4 percent of the body neoplasms 
being sarcomatous, whereas only 3.9 percent, or according to 
my statistics, 2.78 percent, of the newgrowths of the female 
breast are sarcomatous. In regard to its comparative fre- 
quency with carcinoma my statistics show that 4001 out of 
5000 cases of tumors of the breast, or 80.02 percent were car- 
cinomata, whereas only 138, or 2.78, percent were sarcomata. 
Thus it is seen that carcinoma is nearly thirty times as common 
as sarcoma. 

In regard to the etiology of sarcoma little definite is laiown, 
although I am of the opinion that traumatism plays a more 
important role in its production than it does in other mammary 
neoplasms. 



Sarcoma. 163 

The disease is much more frequent in women than in men. 
In a review of the hterature Finsterer was able to collect only 
nine authentic cases occurring in the male sex. He reports 
three others which came to operation in Hochenegg's clinic 
during the thirty years from 187 7-1906. 

I am of the opinion also that some mammary sarcomata owe 
their origin to misplaced embryonal tissue elements, which 
assume active growth in adult life. When such embryonal 
remnants have been deposited in the breast it is very probable 
that even a slight injury may stimulate them to active growth. 
Further investigation is required to determine whether hered- 
ity exerts any causative influence, or whether the occurrence ^ 
of carcinoma in the relatives of those affected with sarcoma in 
any manner predisposes to the development of the latter disease. 
It is not known whether pregnancy, lactation, or the involution- 
ary changes of the breast exert a causative effect. In regard to 
age incidence it may be stated that sarcoma is unquestionably a 
disease of middle life, as is graphically shown by the accom- 
panying chart, which is based upon one hundred cases collected 
from various sources. It has been stated that sarcoma in the 
majority of instances affected young women, and I myself 
was inclined to consider such to be the case until the above- 
mentioned collective investigation showed that one-half the 
cases occurred between the ages of forty and fifty. It must 
be borne in mind, however, that the disease may occur at any 
age. The average age incidence in Finsterer's collection of 
cases affecting the male breast was 45.6 years. 

Pathology. — It has been customary to distinguish two 
principal varieties of mammary sarcoma, namely, the cystic 
or adenosarcoma and the true or pure sarcoma. The 
former originate in the transparent periductal tissue, and 
for this reason I shall adopt the term periductal sarcoma, 
used by Warren, in preference to either of the others above 
mentioned. 



164 



Diseases of the Breast. 



The pure sarcoma originates in the true connective tissue 
stroma of the mamma. 



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Fig. 23. — Showing the age incidence of mammary sarcoma; based on 
100 cases collected from various sources. 



In regard to the relative frequency of the two varieties the 
statistics of Wilhams are interesting. 



According^fo his inves- 



PLATE XXII 




"^ J^^K, 



Sarcoma. Showing gross appearance of tumor and breast when 
removed. —{Maurice H. Richardson.) 



Sarcoma. 165 

tigations the proportion is about 80 percent of the periductal 
to 20 percent of the pure type. 

In regard to the structure of mammary sarcomata it may 
be said that all forms occur — round-celled, spindle-celled, 
giant-celled, alveolar and melanotic. Of the 156 cases studied 
by Gross 68 percent were said to be spindle-celled and 5 
percent giant-celled. I believe that the mixed form, namely, a 
combination of round and spindle cells, is more common by 
far than any of the others. It is unusual to find a tumor 
composed entirely of round or spindle cells. Of course one 
or the other may predominate and thus give distinction to 
the growth. Ernst Siebert states that growths having a pre- 
ponderance of spindle cells are more common in young women, 
whereas those in which round cells predominate occur mostly 
in women of middle life. The average age for the latter was 
found to be 47 J years; for the former 36I years. Further in- 
vestigation will no doubt prove whether this age incidence will 
hold good in a larger number of cases. 

That the round-celled sarcomata are more malignant than 
the spindle-celled is a matter of common knowledge among 
surgeons and pathologists. It grows more rapidly and not un- 
commonly proves fatal within three or four months after its 
onset. With the exception of the very rare melanotic form, 
it is the most deadly which occurs. 

There is a very material difference, both as to the microscopic 
and the gross characteristics, between the periductal sarcoma 
and pure sarcoma. The former, as already stated, originate 
in hyaline tissue around the ducts, and as a result of their lo- 
cation it comes to pass that, as the tumor increases in size, 
the ducts become included in the neoplastic tissue by which 
they are compressed and distorted, so that clefts, and later 
cysts, are formed within the substance of the growth. The 
contents of these cysts, which is often hemorrhagic, exudes 
from the nipple in a considerable percentage of cases. From 



i66 Diseases of the Breast. 

the walls papillary outgrowths not uncommonly project, being 
due to proliferation of the epithelial lining. Glandular ele- 
ments may also be included in the newgrowth, the acini being 
surrounded by sarcomatous tissue or cysts. It was formerly 
believed that these elements developed de novo in the tumor. 
In the stroma of the growth myxomatous degeneration is very 
often seen, and fatty or even calcareous changes have been 
observed. Fatty degeneration if extensive imparts a yellow 
color to the affected area. 

The term myxosarcoma is often applied to those growths 
in which myxomatous degeneration is extensive. 

Cartilage has also been found in mammary sarcomata. 
This condition has already been discussed under enchondroma. 

Periductal sarcomata appear in the breast as round or ovoid 
tumors which are clearly circumscribed and somewhat movable. 
They are encapsulated and as cyst-formation takes place become 
distinctly lobulated. As a rule they are firm and indurated in 
consistency, although occasionally when large cysts are present 
fluctuation can be detected. They vary in size, although as a 
rule they are large when first seen by the surgeon. The super- 
ficial veins of the breast are distended, the skin not uncommonly 
reddened, and as the morbid process advances ulceration is 
wont to take place. Fungous sarcomatous masses then pro- 
trude through the ulcerations, and from them hemorrhages may 
take place. In like manner after the capsule has been broken 
through, neighboring structures may be invaded, the morbid 
process having been known to advance to the ribs and pleura. 

Pure sarcomata differ from the periductal form in that they 
are usually smaller, harder and more regular in shape, and 
that they do not contain cysts. They are encapsulated at 
first, but later may break through the capsule and become dif- 
fuse. Glandular and ductal elements are, of course, not found 
in them. 

Symptoms. — During the early stages of its evolution mam- 



PLATE XXIII. 




Sarcoma 



Sarcoma. 169 

mary sarcoma gives rise to little disturbance, so that it not un- 
commonly escapes detection until it has become large enough 
to attract the patient's attention. When first noticed it may be 
no larger than a marble or a walnut, and as it is painless and in 
no wise annoys the patient, it often happens that little notice is 
taken of it until increase in size begins to produce the fear that it 
may be cancerous. Although cases have been reported in which 
the growth remained stationary for a number of years, I believe 
that most mammary sarcomata increase rapidly in size. At all 
events a time always arrives when rapid growth takes place. 
Pregnancy invariably stimulates them to great activity. I re- 
cently saw a woman eight months pregnant, with apparently a 
large sarcoma growing from the periphery of the axillary quad- 
rant, which was as large as a small cocoanut. At the begin- 
ning of her pregnancy it was, I am told, no larger than a small 
walnut. I saw another case in consultation during my resi- 
dence in Louisville, Kentucky, in a woman four months preg- 
nant. The tumor was situated in the upper hemisphere near 
the periphery. Against my advice the surgeon removed only 
the neoplasm, leaving the gland. Within a month there was 
an enormous fungating mass, and the woman died at the end of 
the sixth month of pregnancy. 

Pain is variable, as a rule, being trivial or altogether absent 
unless ulceration takes place, when it may become severe. 
It has been noticed by several observers, however, that the 
tumor may become slightly painful before and during the 
catamenia, and that swelling may likewise occur at the time. 

The general health is usually not affected until the disease 
has become well advanced and ulceration occurs. When this 
stage is reached, however, the patient becomes emaciated, 
cachectic, and enters upon a rapid decline. As already stated 
round-cell sarcoma usually proves fatal within a few months. 

The diagnosis of large periductal sarcomata, particularly 
those in which cysts have formed, should present little or no 



170 



Diseases of the Breast. 



difficulty. The large, lobulated, movable tumor, with its 
distended superficial veins, together with the history, in most 




Fig. 24. — Sarcoma. {From a photograph loaned by Dr. W. B. Coley.) 

cases at least, of rapid increase in size, will reveal the nature 
of the disease. When ulceration has occurred the protrusion 



Sarcoma. 171 

of fungous sarcomatous masses above referred to will likewise 
make the condition plain. The diagnosis of small sarcomata 
may be very difficult or even impossible. If discovered very 
early in their evolution they may be mistaken for the knot- 
like indurations of chronic mastitis. From carcinomata they are 
to be differentiated by the absence, as a rule, of lymphatic 
involvement, fixation of the skin and retromammary tissues, 
and retraction of the nipple. The nipple, though often displaced, 
is never retracted as it is in carcinoma. The periductal 
fibroma and the fibro-cystadenoma do not grow so rapidly 
as sarcoma, and in the majority of cases affect younger women. 

Prognosis varies, depending upon the character of the growth. 
It is now generally admitted that the periductal sarcoma is 
not so malignant as true sarcoma and that recurrence rarely 
takes place when timely operation is practised. Indeed, War- 
ren states that the tendency to malignancy in the periductal 
sarcoma is very slight. In the Munich cases studied by 
Siebert internal metastases did not occur. 

Pure sarcoma offers a less favorable prognosis, and many 
cases of local recurrence as well as metastasis to the internal 
organs have been reported. As dissemination of the disease 
takes place through the blood-vessels rather than through 
the lymph-channels, metastases may occur even when no signs 
of local recurrence are present. Thus it is that while regional 
recurrences are much less common than in carcinoma, involve- 
ment of the internal organs is more common. Metastases 
have been found in the long bones, the vertebrae, the ribs, the 
brain, heart, lungs, liver, pancreas, ovaries, and peritoneum, 
and in the inguinal and mesenteric lymph glands. 

The fatal course of the disease in pregnant women has 
already been alluded to. 

Treatment consists in complete excision. The breast should 
invariably be amputated, and I also favor clearing out the axilla. 
The necessity of the latter procedure has been questioned. 



172 Diseases of the Breast. 

inasmuch as the axillary glands are, as a rule, not involved. 
Exceptions to the rule, however, do occur, and in view of this 
fact it is well to remove the glands, especially as the more com- 
plete operation will not subject the patient to greater risk and 
may save her from a recurrence. 

Finsterer mentions a case from the Vienna clinic in which 
it was necessary, four months after removal of the breast, to 
clear out the axilla owing to involvement of the lymph glands. 
He also mentions two cases in which the supraclavicular 
glands were enlarged. It is my belief that a thorough 
axillary dissection should always be made, as it adds nothing 
to the danger of the operation and possibly gives a greater 
security to any given case. 



CARCINOMA. 

Etiology.— We possess no more knowledge of the primary 
cause of carcinoma of the breast than we have of its occurrence 
in other organs of the body. To discuss all the theories of its 
causation which have from time to time been propounded would 
not be apposite to our subject, so only those predisposing causes 
which are generally recognized as being more or less important, 
together with certain circumstances which seem to have a 
bearing upon its incidence in the breast, will be fully considered. 

In view of the interest which has of late years been mani- 
fested in the parasitic or germ nature of cancer it may not be 
amiss, however, to discuss this subject before entering into an 
examination of the various supposed etiological factors of its 
production in the mammary gland. 

Many different investigators have found minute spherical 
bodies, surrounded by a delicate membrane and having a 
highly refractive center, in both the protoplasm and nucleus of 
carcinoma cells, and some have believed them to be parasites. 
It yet remains to be proved that they are such or that they are 
in any way related to the production of the disease. In 1904, 
Doyen announced that he had discovered and made cultures 
of a germ which caused cancer, and to which he applied the 
name Micrococcus neoformans. Metchnikoff reported favora- 
bly, though not positively, upon Doyen's assertions. Other 
reports, however, were entirely adverse to them, and at present 
little credence is given to the result of Doyen's indings. 

Simultaneously with the announcement of Doyen's discovery, 
there came a strong article before the Surgical Section of tlie 
International Congress at St. Louis, September, 1904, from 
Professor Orth, of Berlin, combating the germ theory of car- 

173 



174 Diseases of the Breast. 

cinoma, and announcing his adherence to the cellular theory 
in the most positive way. It is very clear that if parasites are 
present they are intracellular and play a secondary and not the 
chief role as an etiological factor. They certainly do not, and 
according to Orth, it is simply impossible that they should bear 
the same etiological factor to cancer that the bacillus of Koch 
does to tuberculosis, and pyogenic cocci to suppuration. The 
language of Orth could not be stronger, and considering its 
high source is, therefore, quoted: "In order to produce pus 
or tuberculosis, etc., it is sufficient for the pus cocci or tubercle 
bacilli to reach suitable media; to bring about a secondary 
cancer it is absolutely necessary that cancer cells from the pri- 
mary or from a similarly created secondary tumor shall reach 
the particular spot, and there continue their growth. In the 
case of secondary cancers we have to do with a successful trans- 
plantation of cancer cells ; in the case of pus foci or tuberculosis 
there occurs a transplantation of the parasites, which do not 
themselves form the new focus, but they impel the local tissue, 
without any cooperation of the tissue of the primary focus, to 
certain pathological changes. Therefore there is an important 
difference between these two classes of phenomena; and one 
cannot conclude that since, in the case of pus foci, tuberculo- 
sis, etc., parasites play a role, this must also necessarily be the 
case in the carcinomatous newgrowths. One can, however, 
say that if in cancer parasites should happen to play a part, 
then these parasites must be of an entirely different kind from 
those above mentioned, because they must bear the closest 
relation to the cancer cells which characterize the growth. 
I do not consider it impossible for an intracellular parasite to 
play a part here; but it is impossible for it to play an indepen- 
dent part. It cannot possibly in itself be the decisive factor in 
the newgrowth; it cannot determine the variety and character 
of the newgrowth, since the cells themselves, and only they do 
this." 



Carcinoma. 175 

The transmission of a cancerous tumor from one individual 
to another, though often cited as evidence of the parasitic nature 
of the disease, proves absolutely nothing further than that a 
successful grafting has taken place. The tumor thus formed 
is the result of the multiplication of the cells introduced and is 
analogous in every way to epidermis when transferred from one 
person to another, as in skin grafting. Until cultures from 
the supposed germs can cause, alone and of themselves, indepen- 
dent of cells, a primary tumor, it is useless to insist upon the 
infectious nature of the disease. Cases of so-called auto-infec- 
tivity prove even less, for here the host has tissues admittedly 
prone to degeneration ; and it is easy to understand how success- 
ful grafting can foUowJprolonged contact. 

I am not inclined to attribute much value to the results 
obtained by inoculating and grafting experiments upon ani- 
mals, as mice for example. 

The rare, if not unheard of infection, of operating surgeons 
by cancerous patients is the strongest possible evidence against 
the infectious nature of the disease. 

To pass now from these preliminary considerations to a 
study of those conditions which bear upon the occurrence of 
carcinoma in the mammary gland, it may be stated that sex, 
age, and race undoubtedly exercise a considerable influence 
over the development of the disease. Thus the proponderance 
of cases occurring in women is a fact so firmly established that 
no figures need be adduced to confirm it. 

Not more than one percent of all cases occur in men. Out 
of 1460 cases of mammary carcinoma studied by Keyser only 
10 affected the male breast; of 307 cases treated at the Johns 
Hopkins Hospital, Warfield states that only 3 were in men; 
Fantino found only i case in 228, and Sick found only 2 
in 616. These figures do not show such a high percentage 
among men as those of some of the older authors, for instance 
Billroth, who stated the percentage to be 2.82. 



176 



Diseases of the Breast. 



So, too, it has long been known that age constitutes an impor- 
tant etiological factor, a vast majority of all cases occurring in 
women in or past middle life, usually at about the time of the 
climacteric. Various statistics, though showing minor differ- 
ences, are in the main harmonious upon this point. Thus, 
for example, Gross's, Williams's and Mahler's analysis of cases 




all give an average age incidence of forty-eight years, Sprengel's 
show fifty years as the most common period of its occurrence, 
Gebele's 50.8 years, and Sick's 52.3 years. My own statistics, 
presented graphically in the accompanying chart, confirm pre- 
vious observations, in so far as they show the greatest incidence 
of the malady to be in middle life. It must be remembered, 
however, that there are more women living between the ages 



Carcinoma. 177 

of forty and sixty than there are over sixty. If there were as 
many women over sixty ahve as there are between forty or 
forty-five and sixty, I doubt not that fully as great a percentage 
of cases would be found in them as among the others. It 
will be seen from the accompanying chart that 21.5 percent 
of the 5000 cases were in women past sixty. It will also 
be observed that the percentage of cases occurring in the 
sixth decade of life is 1.5 percent greater than those occurring 
in the fifth decade. Had it been possible to divide the entire 
number of cases into quinquenial instead of decennial periods, 
it is probable that only a very minute difference, if indeed any 
whatsoever, would have been found between the periods from 
forty-five to fifty and fifty to fifty-five. 

The most striking thing shown by the chart is the sharp rise 
in morbidity which occurs after the fortieth year. The next 
one, and one, too, which is of quite as great importance, is 
that 9 percent, or nearly one-tenth of the entire 5000 cases, 
occurred in women between the ages of twenty and thirty. 
These latter figures, based as they are upon a sufficiently large 
number of cases to insure at least a fair degree of authenticity, 
strengthen the view which I had formerly often expressed rela- 
tive to the incidence of mammary carcinoma in young women. 
Between the years 1898 and 1906 I operated upon five cases of 
cancer of the breast occurring in patients aged 23, 25, 25, 27, 
and 28 years respectively. In all but one of these cases — and 
that in the case of the patient aged 23 years — the tumor was 
a typical scirrhus carcinoma. McCosh, Richardson, Park, 
and Warren have operated on patients aged 19, 21, 22, and 
22 years respectively, and in the Tubingen cases analyzed 
by Mahler there was one patient aged 26 years. These cir- 
cumstances led me to believe that mammary carcinoma is 
much more common in young women than it is supposed to be, 
and it was rather for the purpose of securing information on 
this matter than for corroborating: that which has come to be 



178 



Diseases of the Breast. 



generally accepted regarding its most frequent occurrence in 
middle aged women that I had the age incidence of the disease 





Between 
20 and 30 
years of age. 


Between 
30 and 40 
years of age. 


Between 

40 and 50 
years of age. 


Between 
50 and GO 

years of age. 


Over 60 
years of age. 


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Fig. 26. — Showing the age incidence of mammary carcinoma; based on 5000 
cases collected from various hospital reports and other sources. 

investigated in a large number of cases. The result of this 
investigation, as herein portrayed, is significant. 
It has been stated that mammary cancer affects the male 



Carcinoma. 179 

at a more advanced age than the female. In nine cases Keyser 
found the average age to be 61.5 years. Wihiams states that 
the average age is 50 years. The eight cases which I have seen 
were in elderly men. J. Chalmers DaCosta, however, has 
seen two cases in men under 40 years of age. In view of the 
paucity of cases analyzed, I am of the opinion that further inves- 
tigation is necessary to determine the difference in the age inci- 
dence of the disease in the two sexes. It is interesting to note 
that a case of mammary cancer occurring in a man 91 years 
old has been reported. This is said to be the oldest case on 
record. (Lunn, Trans. Path. Soc. of London, Vol. xlviii.) 

In regard to racial influence, it may be said that races such 
as the American negroes and Indians, which were formerly 
considered immune, have become susceptible since living under 
changed environments. This is especially true of the negro, 
and applies to carcinoma of various organs, as shown by my 
investigations at the Louisville City Hospital. In lesser degree 
it is also true of the Indian. All observers seem to agree that 
savages are peculiarly exempt from cancer, and that Africans 
are the most immune of all. All early writers testified to the 
immunity of the Africans in their adopted country and, indeed, 
I think it cannot be doubted that cancer was rare with them 
up to fifty years ago. These early writings, however, have too 
much influenced practitioners of this generation, and many 
still believe that the disease is rare among negroes because it 
was so a few generations ago. 

Far from being uncommon in the mammary gland, carcinoma 
is as frequently met with in American negroes as it is in the 
American white races. I have seen a dozen cases myself. 
The first case of cancer of the breast I ever saw was in a negress 
about forty years of age, as black as a crow's wing. She died 
from recurrence after operation, at the usual time and in the 
usual way, confirming the clinical diagnosis. In at least six 
of the other cases, too, the diagnosis was confirmed both by 



i8o Diseases of the Breast. 

microscopic examination of the neoplasm and the subsequent 
death of the patient from recurrence. 

There were 839 cases of cancer of the breast reported in the 
eleventh census; 811 females, 28 males. One occurred under 15 
years of age; 163 between 15 and 45; and 670 at and over 45; 
rate of death to 100,000 inhabitants: females 823; males 0.29; 
age 45 to 65, 30.08; 65 and over, 50. Death rate practically 
the same in white and colored, being 4.27 in the former and 4.19 
in the latter. 

The records of the Louisville City Hospital for twenty years 
show that three-fifths of the cases were white and two-fifths 
colored, though the latter represent but one-third of the Hos- 
pital population. 

I am of the opinion that the negro, although still enjoying 
a comparative immunity to carcinoma in general, being excep- 
tionally free from carcinoma of the lip, tongue, penis, etc., is 
more obnoxious to cancer of the breast and uterus than the 
white. 

According to W. Roger Williams, who has investigated the 
subject carefully, mammary carcinoma is common in China. 
He quotes Cantlie, who states that of 114 cases of carcinoma 
affecting Chinese patients ^8 were mammary, and also states 
that II out of 30 operations for malignant disease performed 
in one year at Dr. Kerr's Hospital in Canton were for neoplasms 
of the breast. 

It has been said that Jews are less subject to carcinoma 
than other white races, but this statement I believe to be erro- 
neous. It certainly is not in accord with the result of observa- 
tions made in the United States. 

With the passing of the constitutional theory of cancer and 
the demonstration and acceptance of its local origin about thirty- 
five years ago, there began a tendency to minimize the influence 
of heredity as a predisposing cause. This tendency has been 
carried too far, just as has been the case with tuberculosis. 



Carcinoma. i8i 

The disease, of course, is not inherited, but the soil is prepared 
and made ready should the seed be sown at a time when the 
epithelial tissues are prone to run wild. In my own experience 
at least one-third of all cases which come to operation have 
been preceded by one or more cases of cancer, usually of the 
breast, in the family. 

Delbet, who has studied this subject carefully, found from 
analysis of a large series of statistics that the number of 
cases in which hereditary influence was present varies between 
5 and lo percent. 

Recent statistics tend to show that carcinoma of the breast 
is more common in married women, and especially those who 
have borne and nursed children, than it is in single women. 
I cannot agree with those who believe that it is equally common 
in the single and married, the sterile and fruitful. 

Certainly some consideration must be given to such results 
as have been derived from the examination of hundreds of 
recorded cases, as for example those analyzed by Guleke, who 
found that of 982 patients treated in von Bergmann's clinic 90 
percent had borne children. As those familiar with the work 
of the late S. W. Gross may remember, he found that 316 out of 
416 women affected with mammary cancer had nursed children. 

In view of these and other similar findings, it has been in- 
ferred that a direct causative relation exists between the func- 
tional activity of the gland and the occurrence of carcinoma. 
The periodic changes which take place in the breast as the 
result of pregnancy and lactation are associated with evolution 
of tissue, which may predispose to the proliferation of epithel- 
ium in the acini, thereby leading to the development of cancer. 
Perhaps the inflammatory processes to which the gland is often 
subjected during the period of lactation may lead to the forma- 
tion of connective tissue which compresses the acini, produces 
irritation, and thus causes cell proliferation. 

Granted that there be a causative relation between functional 



i82 Diseases of the Breast. 

evolution and involution of the mamma and carcinoma, there 
yet remains a percentage of cases in which this factor can be 
entirely eliminated. Every surgeon of experience has seen 
cases of cancer of thq breast in maiden ladies whose sexual 
life has beyond any doubt been absolutely negative. In such 
cases it would not be illogical to infer that the organ assumes 
morbid activity to compensate for the deprivation of normal 
function which it has sustained. 

Traumatism, chronic inflammation, and mammary ab- 
scess have often been cited as predisposing causes. The exact 
etiologic relation, if indeed there be any, which exists between 
these conditions is not known. Statistics relative to the influ- 
ence of mastitis show such wide variations that they are totally 
useless. Thus, for example, Winiwarter found a history of 
mastitis in twenty-four out of one hundred and fourteen cases, 
whereas Billroth obtained a similar history in only seven out 
of two hundred and eighty- two cases. It is interesting to note 
that in looo cases observed by Williams there was only one in 
which the disease immediately followed injury. Moreover, 
out of 137 women whom he interrogated, only 35, or 25.5 per- 
cent, gave a history of antecedent injury. Of course in the 
remaining 74.5 percent there may have been a considerable 
number who had received injuries which had passed unnoticed 
or been forgotten. 

Cancer of the male breast seems to have been associated with 
injury in a considerable number of cases, and in many of these 
the relation between the traumatism sustained and the develop- 
ment of the disease has undoubtedly been one of cause and 
effect. In two of the eight cases which have come under my 
observation there was a history of traumatism; one was in a 
shoemaker who for years had pressed a last against his breast, 
and the other was in a laborer who was in the habit of resting 
the handle of his shovel against the breast. Cases similar to 
these have been reported by other surgeons. 



Carcinoma. 183 

Personally, I feel inclined to consider these factors as more 
or less influential in the production of the disease, particularly 
since all forms of carcinoma are generally found at points sub- 
ject to persistent irritation. 

It has been stated that the left breast is more often affected 
than the right. Although I think I have seen more cases in 
which the former was affected than the latter, I have never 
believed that the examination of a large number of cases would 
show much difference as to the frequency with which the two 




Fig. 27.— Bilateral mammary carcinoma. 

breasts are attacked. The recent investigations of Sick, of 
Hamburg, are very significant in regard to this matter. He 
found that in 2,163 cases occurring in the practice of 10 Europ- 
ean surgeons, the left breast was affected 1,088 times and the 
right 1,075. The difference is too small to consider. 

The occurrence of carcinoma in both breasts is rare, althoudi 



184 Diseases of the Breast. 

it is probably more common than many have been led to believe 
as the result of individual experience. Personally I have seen 
only two cases. A review of the literature of this subject has 
been of great interest to me, and as some of the statistics of 
well-known surgeons may not be without interest to the reader, 
I will quote a number of series of cases here. 

Out of 132 cases of mammary carcinoma which came to 
operation in the Gottingen surgical clinic between the years 
1875 and 1885, Hildebrandt states that there were six in which 
both breasts were affected. A like number was found out of 250 
cases reported from Esmarch's clinic at Kiel. Out of 228 cases 
operated on at the Augusta Hospital in Berlin there were only 
two in which both breasts were affected. In a report of 200 
cases treated at the General Hospital at Copenhagen between the 
years 1870 and 1888 Poulsen states that the disease was present 
in both breasts in 1 1 cases. Thus it is seen that there is no uni- 
formity as to the percentage of cases in which the disease is 
bilateral. 

Unfortunately details in regard to the involvement of the 
second breast are not sufficiently reported in these series 
of cases to permit a careful analysis to be made. It would 
be most interesting to determine the average time at which 
disease appeared in the second breast after the first one 
became affected. I have been able to secure only meager 
information concerning this matter. Albert describes a case 
in which both breasts were apparently affected simultaneously, 
and Poulsen mentions another in which each breast presented 
a tumor of equal size, both of which Vv^ere said to be of one year's 
duration. Anton Beck in his Munich Thesis, 1904, men- 
tions two cases occurring in the service of Prof. Klausner in 
which the tumor in each breast was said by the patient to have 
appeared simultaneously ; in one of these cases the growths were 
of two years' duration, in the other of three months' duration. 
Thus it is seen that there are apparently authentic cases in 



PLATE XXIV 



( 



Adenocarcinoma.— (Jfciur^ee H. Richardson.) 



Carcinoma. 185 

which both breasts become diseased at the same time, but of 
course a certain allowance must be made for the accuracy of the 
patient's observation. In the two cases of Klausner there was 
a decided difference in the size of the tumors in the two breasts. 
x\lbert's case did not come to operation and so, of course, posi- 
tive data as to the size and nature of the tumors could not be 
obtained. 

While it is of course possible that the carcinomatous process 
might begin simultaneously in both breasts, I am of the opinion 
that one is always affected before the other and that the involve- 
ment of the second breast is metastatic, the disease being con- 
veyed by the lympathics. It will be remembered that there is 
a set of superficial lymphatics over the sternal half of the gland 
which pass through the second and fourth intercostal spaces to 
discharge their contents into the nodes of the anterior medias- 
tinum. Some of these vessels occasionally interlace with those 
of the opposite side, so that virus from a tumor adherent to the 
skin over one breast might be transmitted to the other. Direct 
permeation of the disease through the fascial lymphatic plexus 
might also occur. 

The term bilateral carcinoma has also been applied to those 
cases in which recurrence of the disease took place after ampu- 
tation had been performed and the disease later developed in the 
second breast, as well as in those in which the second breast 
became affected after amputation of the first had been per- 
formed and was not followed by local recurrence. To the 
frequency of the latter occurrence Rotter has called particular 
attention. Out of 35 recurrences he found that 6 took place in 
the other breast. Late involvement of the second breast is of 
course explained by transference of the cancer elements through 
the lymphatics. 

In conclusion, I would plainly state that despite the fascinat- 
ing theories advanced and the information derived from the 
study of large numbers of statistics, I still remain an agnostic, 



i86 Diseases of the Breast. 

denying that any theory yet advanced gives entire satisfaction to 
one viewing the subject from a Hberal point of view. 

That race, environment, temperament, habits, trauma, and 
possibly diet may have some influence in the etiology of cancer 
may be allowed, but it would seem that more than one cause 
is influential, the primary or essential causes yet remaining 
unknown. 

Pathology. — Carcinoma can be divided into adenocarci- 
noma, medullary and scirrhus carcinoma, carcinoma simplex, 
gelatinous carcinoma and carcinomatous cyst. All arise from 
the epithelium lining the acini, but are classified under 
difi'erent heads because of the arrangement of, and the vary- 
ing relations of the connective tissue stroma to, the tumor 
cells. 

Adenocarcinoma was first described by Halsted in 1898, 
and since that time it has come to be recognized as a definite 
pathological and clinical entity. This form of the disease 
represents the first step in the deviation from typical epithelial 
proliferation. 

Adenocarcinoma grows comparatively slowly, but steadily, 
to a rather large size, when the skin breaks down and a fungating 
mass is formed, which is soft to the touch and often overhangs 
the skin edge of the growth; that is, exhibits a tendency to become 
pedunculated. This is quite characteristic of the growth. The 
lymph nodes are rarely invaded until very late in the disease, 
when the tumor has been converted into one of the other forms 
of carcinoma. When enlarged nodes have been found in the 
earlier stages, the enlargement was invariably due to endothelial 
hyperplasia. 

On section through the breast, the cut surface of the tumor 
resembles the other carcinomata, especially the simplex, being 
softer than and not quite so infiltrating as the scirrhus, though 
usually not quite so soft as the medullary carcinoma. On sec- 



PLATE XXV 




Adenocarcinoma.— (JjTaicrice H. Richardson.) 



PLATE XXVI. 




Adenocarcinoma. Microscopic appearance. 



PLATE XXVII. 




Section showing areas of adenocarcinoma and medullary care 



PLATE XXVIII 




Meaullary Carcinoma. Showing appearance of breasi and tumor whQU 
removed.— (JMawnce H. Richardson.) 



Carcinoma. 191 

tion it does not usually bulge, but some sections exhibit slight 
cupping, and on pressure extrude small, yellowish, worm-like 
plugs of epithelium. 

Microscopically, typical portions of the tumor show abnormal 
acini formation, the acini forming large tubular spaces lined 
with epithehum, which, in places, is very thick. As described 
by Halsted, the cells in some areas form combinations which 
result in the formation of gland-like figures, circles, tubes, 
columns and minute papillae. Even when the tubes are com- 
pletely filled and there is no lumen, the cells exhibit the same 
tendency to make definite figures and cell combinations. Some- 
times the different figures anastomose in such a manner as to 
make a rather open mesh work. 

The above description applies only to the typical portions of 
the tumor. Many tumors show all stages and gradations from 
the above type, varying from sections closely resembling the 
adenomata to simplex and scirrhus carcinomata of the most 
atypical variety. In certain areas, the cells can be seen to be 
breaking through the basement membrane and entering the 
connective tissue stroma, to be carried along in the lymph 
spaces, there to set up an atypical form of growth or possibly 
become localized and form a small nodule, the cells of which 
exhibit the same tendency to form figures as the parent growth. 
Halsted has also described a bitypical form in which the ordi- 
nary carcinoma is seen to be infiltrating the stroma separating 
the tubes of a typical adenocarcinoma. 

Although adenocarcinoma marks the first step in the deviation 
from typical epithelial proliferation, it is one of the rarer forms 
of carcinoma. As a rule when atypical proliferation of the 
epithelium once begins, it loses all semblance to glandular 
formation and multiplies rapidly in preformed connective 
tissue or lymph spaces, its shape being determined by the 
rapidity of the growth and the space in which it proliferates. 

These more atypical forms of cancer have been divided into 



192 Diseases of the Breast. 

medullary or soft cancer and scirrhus or hard cancer. The 
carcinoma simplex is an intermediate form, not as hard as 
the scirrhus nor as soft as the medullary. From this it will 
be seen that the only differences are based upon the relative 
amounts of connective tissue and tumor tissue present. 

Macroscopically, the medullary carcinoma usually appears 
as a large, soft, more or less localized nodule of a pale or yellow- 
ish red hue, which may be hyperemic and may show areas of 
hemorrhage. It is usually quite rapid in growth and, when it 
approaches the skin, tends to ulcerate, forming large, soft, 
flabby granulations. Its borders, while not encapsulated, 
ordinarily can be readily distinguished from the surrounding 
healthy tissue. On section, the growth offers but little resistance 
to the passage of the knife, the cut surface of the tumor bulging 
above the surface of the normal tissue. On expression or 
scraping with the knife, the so-called cancer juice may be ob- 
tained, consisting of the degenerated centers of the carcinomat- 
ous cell nests. 

Microscopically, the growth can be seen to be composed of 
large, irregular masses of carcinomatous cells surrounded by 
delicate trabeculae of connective tissue. In this form of carci- 
noma the cell masses are more or less polygonal in shape, while 
the cells themselves are also irregular, owing to mutual com- 
pression. The striking characteristic of the growth is the great 
preponderance of the epithelium over the connective tissue 
stroma. 

Owing to the large size of the cancer nests and the small 
amount of stroma and consequently poor blood supply, the 
centers of the carcinomatous masses are prone to degeneration, 
so that they frequently show necrotic cells in addition to infil- 
trated leucocytes. The stroma of the tumor, especially at the 
edge of the mass, shows a definite round-cell infiltration. 

Carcinoma simplex, occupying as it does an intermediate 
position between medullary and the scirrhus carcinoma, may 



PLATE XXIX 






Medullary Carcinomata. A. Ulceratinjr Tumor. B. S.H-tion iluvuoh bron^t 
and tumor.- Ulaur ice H. liicharason.) 



PLATE XXX. 




Medullary carcinoma. Microscopic appearance. 



13 



Carcinoma. 195 

resemble either, according to which form predominates in the 
microscopical picture. It is, however, never as soft as the 
medullary nor quite as hard as the scirrhus. It usually exhibits 
more of an infiltrating appearance than does the medullary, re- 
sembling the scirrhus in that particular. 

Microscopically it is characterized by the more equal distri- 
bution of the carcinomatous and connective tissue. The con- 
nective tissue trabeculas are thicker and the cell nests smaller. 
The form of the nests may vary, some being polygonal in shape, 
as in the medullary, and others forming wide, elongated clefts 
or tubes, the so-called tubular carcinoma of Billroth. The one 
tumor may show three different stages of growth, namely, 
medullary, scirrhus and the intermediate stage described 
above. It is much more common than is the true medullary 
growth. 

Scirrhus carcinoma is characterized by contraction of the 
stroma and atrophy of the epithelium. The growth presents 
as a hard, irregular mass, usually adherent to the skin and not 
sharply outlined. To my students I have often likened this 
tumor when cut into to an unripe pear or a turnip, so firm and 
hard it is and so resistant to the knife. Upon section it creaks, 
a circumstance due to the abundance of its stroma. As the 
morbid process progresses, adherence to the pectoral fascia oc- 
curs, as the result of which the growth becomes firmly fixed to 
the thoracic wall. 

In scirrhus there is sometimes an associated dense infiltra- 
tion of the skin around the primary growth which may be- 
come so extensive as to involve the entire thoracic wall. Mi- 
croscopic examination of the thickened, indurated integuments 
may fail to reveal cancer cells, although as time passes the malig- 
nant nature of the process is manifested by the formation of 
nodules in the skin, and in some cases by ulceration. This 
condition, to which the term cancer en cuirassc is applied, has 
long been thought to be due to invasion of the superficial lym- 



196 Diseases of the Breast. 

phatic channels by cancer cells. Recently, however, W. S. 
Handley, of London, has compared it, in its early stages at 
least, with the bra^^Tiy thickening of the integuments of the arm 
which often occurs in mammary carcinoma, and asserted that 
it is identical with the pachydermia which occurs in elephan- 
tiasis. He believes the condition to be dependent upon obstruc- 
tion to the return of lymph from the skin, which obstruction 
in turn is due to cancerous permeation of the deep fascial lym- 
phatic plexus or to actual destruction of the vessels by perilym- 
phatic fibrosis. This theor}', which is based upon careful 
microscopic examination of tissues taken from the infiltrated 
thoracic wall, is worthy of consideration, particularly since it 
has been long known that cancerous epithelium may not be 
found even after the most careful examination of serial sections 
taken from tissues removed early in the course of the infiltrative 
process. It is interesting to note that in examining sections of 
cancer Handley has never observed involvement of the deep 
cutaneous plexus. He states, however, that the dermis close 
to subcutaneous cancer nodules is often slightly or not at all 
infiltrated by the growth. 

In other cases of scirrhus the tumor undergoes complete 
or almost complete fibrosis. Here the epithehum is no doubt 
destroyed by the constantly increasing stroma. In some cases 
of this kind shrinkage may takej)lace in a weU-developed tumor, 
so that only a tough, dense mass corresponding to what was 
orio-inallv the center of the 2;rowth mav remain. In other 
cases in which the formation of fibrous tissue has been more 
rapid from the beginning than the proliferation of epithehum, 
a contraction of the glandular elements and of the skin, which 
is usually fixed to the structures beneath, is the only morbid 
gross alteration perceptible. 

The results of microscopic examination of such a scirrhus 
carcinoma, to which the name atrophic or withering has been 
given, are in strict accord with the macroscopic characteristics. 



PLATE XXXI 



W-^. 




(Scirrhus Carcinoma.— (Jfawricc H. Bichardson.) 



PLATE XXXII. 




Scirrhus carcinoma. Microscopic appearance. 



Carcinoma. 199 

Compact bundles of fibrous tissue, with here and there a few 
scattered epithehal cells, or in some sections none whatsoever, 
are revealed. 

Naturally the dissemination of the malignant elements of 
carcinoma from such a growth will be slower than in the other 
varieties of scirrhus, just as it is slower in ordinary scirrhus than 
in the medullary variety. For this reason the course of wither- 
ing carinoma is very protracted, so that a person affected with 
it may live for years. Allusion to this circumstance will be 
made again under the subject of prognosis. 

Gelatinous carcinoma (Billroth) or mucoid carcinoma, 
which is frequently incorrectly called colloid carcinoma, is a 
very rare form* of cancer in which the cells have undergone 
complete mucoid degeneration, so that when seen microscopic- 
ally little more than the connective tissue stroma can be 
distinguished surrounding rather large spaces which contain 
a mucoid material. Here and there small clusters of a few 
carcinomatous cells can be found undergoing mucoid degenera- 
tion. The growth shows very little tendency to infiltrate, and 
is one of the most benign of all the carcinomata of the breast. 
It should not be called colloid carcinoma because true colloid 
material is not formed. 

Another very rare form of mammary carcinoma is the car- 
cinomatous cyst, a malignant cystic tumor the walls of which 
are infiltrated with carcinomatous epithehum. Hard carcinom- 
atous masses have also been observed o-rowinoj from the inner 
wall of the cyst. Papillary excrescences, however, are never 
present, a circumstance which distinguishes the neoplasm from 
papillary cystadenoma which has undergone cancerous degen- 
eration. Very frequently the carcinomatous process extends 
from the cyst wall to the surrounding tissues, with the result 
that a considerable degree of induration is produced. Involve- 
ment of the anatomically associated lymph glands occurs as 
in the other forms of mammary carcinoma. A peculiar charac- 



200 Diseases of the Breast. 

tistic of these cysts is that the contents is almost invariably 
bloody. 

Bloodgood, who has studied the subject carefuhy, believes 
this to be the rarest form of cancerous disease affecting the 
breast. 

Carcinomatous cysts grow rapidly, but develop signs of malig- 
nancy slowly. 

It has alreadv been stated that carcinoma mav orisrinate in 
a breast affected with chronic mastitis (see page 40). In such 
cases the macroscopic appearance of the gland corresponds to 
that of the primary morbid changes, and it is only upon mi- 
croscopic examination that the carcinomatous epithelium is 
found embedded in the dense fibrous stroma. The malignant 
process sometimes invades the surrounding tissues, in which 
case it may be seen to follow the lymphatics. I recently am- 
putated a breast which was riddled with small abscesses, and 
which I took to be tuberculous. Upon microscopic examina- 
tion, however. Dr. ]\IcFarland found no signs of tuberculosis, 
but " an associated medullary carcinoma, growing without 
stroma, its cells being mingled with the pus-cells of the 
abscess." 

Dr. ^^IcFarland states that this is one of the most interest- 
ing tumors he has ever seen (Fig. 2S). 

The dissemination of carcinoma is one of the most interest- 
ing subjects in pathology, and one also upon which rational cura- 
tive treatment must be based. The increased percentage of cures 
of mammarv carcinoma obtained in the last few vears is due 
essentially to our increased knowledge of the normal and patho- 
logic anatomy of the lymphatics which drain the breast, or in 
other words to the manner in which a primary carcinomatous 
focus in the mamma may invade contiguous and remote struc- 
tures of the body. 

Three routes of dissemination wih be discussed here : namely, 
(i) transference of cancerous cells directly through the 



PLATE XXXM 




Gelatinous Carcinoma. — {Maurice H. Richardson.) 



Carcinoma. 



201 



main lymph channels; (2) direct extension of the carci- 
nomatous process by growth of cells along the minute 
lymphatic vessels; (3) dissemination through the blood 
current. 

Early in the course of mammary carcinoma the anatomically 
associated lymph glands of the axilla become infected, the 




Fig. 28. — Carcinoma associated with multiple small abscesses of the 
breast, the latter evidently being primary. 



morbid elements being undoubtedly transmitted directly through 
the main lymphatic channels of the breast. It will be remem- 
bered that not only does the main set of superficial lymphatic 
channels described by Sappey empty into the axillary glands, 
but that a deep set originating in the mucous membrane of 
the ducts and acini of the outer half of the gland also reaches 
the axilla, where it unites with the superficial plexus to form 



202 Diseases of the Breast. 

an extensive network which extends upwards around the axillary 
vein (see page lo). 

A gland examined microscopically during the early period of 
its invasion will show a few epithelial cells in the subcapsular 
lymph sinus at the point of entry of the afferent lymphatic 
vessels (Stiles). (See Plate XXXIV.) Gradually the process 
of proliferation extends until finally the whole gland becomes 
carcinomatous; if the fibrous capsule is broken through, as not 
uncommonly happens, the adjacent tissues become infiltrated 
with cancer cells. Here gland and surrounding tissue form a 
firm immovable mass. Adherence to the integuments, and 
later ulceration, often occur. The different chains of glands 
may become infected one after another, either by direct ad- 
vance of the morbid process or by transference of cancer cells 
through the communicating lymphatic vessels, or in both ways. 

Involvement of the axillary glands on the opposite side 
is an occurrence of considerable frequency, and one which is 
prone to occur in late cases. It has been customary to explain 
this phenomenon by assuming that infection takes place through 
the superficial lymphatics which drain the inner half of the 
mamma, some of which occasionally interlace with those of 
the opposite side. Handley, however, attributes it to involve- 
ment of the trunk lymphatics of the opposite side, due to per- 
meation of the malignant process beyond the middle line, the 
disease advancing along the minute vessels of the fascial lym- 
phatic plexus. He believes involvement of the opposite breast to 
take place in the same way. Handley's statistics concerning 
the occurrence of this phenomenon are very instructive. Out 
of 422 cases which he studied involvement of the second breast 
took place in 66, or 15 percent. "It was present in 18 percent 
of the Middlesex Hospital (late) cases, and in only 5 percent of 
the Guy's Hospital (early) cases." Thus it is seen to be a late 
occurrence in the life history of the disease. 

The supraclavicular glands may become infected through 



PLATE XXXIV. 




Lymph node in which carcinoma has replaced normal tissue 
except at the periphery. 



Carcinoma. 205 

the efferent lymphatic channels from the axillary glands or by 
way of the set of cutaneous vessels recently described by Poir- 
ier and Cuneo, which drains the upper half of the breast and 
passes directly over the clavicle to empty into the glands above 
that bone. 

The mediastinal glands may become implicated through 
that set of deep lymphatics which drains the inner half of the 
breast, and after perforating the second and fourth intercostal 
spaces empty directly into these glands. This set, moreover, 
is joined by some superficial vessels which likewise pour their 
contents into the mediastinal glands. 

The same changes which have been described as occurring 
in the axillary glands take place in these. They may become 
so much enlarged as to press the sternum forward. 

The deep set of vessels just mentioned communicate with the 
lymphatics of the liver; hence invasion of this organ may be 
explained by reason of lymphatic dissemination. This matter 
will be referred to again in discussing visceral dissemination. 

Involvement of the spinal cord may also be explained by 
lymphatic invasion, the cancerous elements being transmitted 
by that set of lymphatics draining the middle of the base of the 
mammary gland and the retromammary tissues. A portion of 
these vessels perforate the intercostal spaces and accompany 
the blood-vessels to the spine. 

Mention has already been made of adherence of the carci- 
nomatous mamma to the pectoral fascia. (See Plate XXXV.) 
That lymphatic involvement of the fascia may occur before the 
breast becomes adherent to it is a well-known fact, but one I 
beheve to which too httle attention has been paid. Heidenhain, 
however, called attention to it as long ago as 1889. In twelve 
out of eighteen cases he found cancerous lymphatics passing 
from the mamma to this fascia. 

The lymphatics of the pectoral fascia are merely a part of the 
deep fascial lymphatic plexus already described (see page 11). 



206 Diseases of the Breast. 

In addition to the various results of lymphatic infection al- 
ready mentioned, it is easy to understand why involvement of 
the inguinal glands as well as the axillary and supraclavicular 
occurs, if it be borne in mind that the main trunks of this plexus 
emptying into these glands may become contaminated by way 
of the minute vessels which connect them as a network with 
the larger channels nearer the region of the breast. 

The fascial lymphatic plexus is the anatomical basis upon 
which Handley's theory of permeation, or extension of the 
carcinomatous process by direct growth through the minute 
lymphatic vessels, is founded. 

Before entering upon a discussion of this theory, however, 
I shall say something concerning a method of dissemination 
known as retrograde lymphatic embolism. It has been asserted 
that obstruction of a set of lymph glands would result in the 
production of a reflux current inthe vessels emptying into them, 
so that the cancerous elements would be transferred in the op- 
posite direction and carried to the glands of the unaffected 
axilla, the other breast, the inguinal region, etc. Such a sup- 
position I believe to be untenable for the reason that the lymph 
stream is at its best weak, even in the larger trunks, and partic- 
ularly so in the minute plexus into which the branches of the 
trunks divide. Furthermore the circumstance that the larger 
trunks contain valves render the occurrence of regurgitation 
even more improbable. 

Mr. Handley, of London, who has recently published a 
complete report of his studies on - carcinoma,* believes that 
cancer spreads in the parieties by direct growth through the 
vessels of the fascial lymphatic plexus, and that the cancer 
cells are not transmitted as emboli through the larger lym- 
phatic trunks until late in the course of the disease. To this 
process he has applied the term permeation. His researches 

* Cancer of the Breast and its Operative Treatment, John ?durray, London, 
1906. 



PLATE XXXV. 




Carcinomatous invasion of the great pectoral muscle. 



Carcinoma. 209 

show that secondary deposits first appear in the region of the 
primary focus, but that as the disease progresses they occur 
further and further away from the site of the original neo- 
plasm. In late cases he often found that though no permeated 
lymphatics could be detected in the near vicinity of the or- 
iginal tumor, examination of long radial sections of the skin 
and subjacent tissues revealed the presence of the disease, 
which had invaded the minute vessels of the fascial lymphatic 
plexus. Thus the boundary of the malignant process, that is, 
the microscopic growing edge of the carcinoma, is found far 
beyond the limit of macroscopically perceptible disease. ''The 
absence of permeated lymphatics in the area intervening 
between the annular microscopic growing edge and the primary 
neoplasm is due to the destruction, after a time, of the cancerous 
permeated lymphatics by the defensive process of perilymphatic 
fibrosis." It was found, however, that isolated nodules in the 
skin and muscles may be present in the area in which lymphatic 
involvement has disappeared. These lesions are attributed to 
failure on the part of the tissues to produce, at isolated points, 
a protective zone of fibrosis around the lymphatic vessels. 
Thus, although the permeated lymphatics along which the 
morbid process extended become obliterated, the isolated car- 
cinomatous lesions nevertheless arise in continuity with the 
primary neoplasm. 

Mr. Handley also believes that visceral dissemination 
takes place as the result of permeation along the fine anasto- 
moses which connect the fascial lymphatic plexus with the sub- 
endothelial lymphatic plexuses of the pleura and peritoneum 
and with the mediastinal and portal glands. The cancer 
cells, he thinks, then escape into the pleural and peritoneal 
cavities and become implanted upon the viscera, in this manner 
giving rise to the metastases which have usually been thought 
to be due to dissemination through the lymph and blood cur- 
rents. 

T4 



2IO Diseases of the Breast. 

This theory of Mr. Handley's, particularly in so far as it 
relates to invasion of the parieties, seems to be founded upon 
accurate observation. That extension of the malignant proc- 
ess along the lines of the minute lymphatic vessels is an actual 
occurrence, he seems to have demonstrated by careful micro- 
scopic study of the diseased tissues. Moreover, it is plausible 
that when permeation has extended to the epigastric triangle, 
where only a layer of fibrous tissue separates the cancerous 
lymphatics of the deep fascia from the subserous fat beneath, 
still further progress of the cancerous disease may take place 
through the minute lymphatics of the separating layer of fascia. 

I am not, however, prepared to accept this theory of visceral 
dissemination nor to adopt it in explanation of the involvement 
of the axillary and mediastinal glands and the opposite breast, 
for I believe that our knowledge of the anatomy of the larger 
lymphatic channels enables us to explain not only the inva- 
sion of the latter structures but infection of the liver and the 
portal glands as well. Allusion has already been made to the 
fact that a set of deep lymphatics which drain the inner half 
of the breast communicate with the lymphatics of the liver. 
This anatomical relation seems to me to afford an adequate 
explanation of the presence of cancerous nodules in the latter 
organ, particularly in cases in which extensive parietal invasion 
has not occurred and in which the pleura is found to be free 
from secondary deposits. The fact that the liver, as is generally 
conceded, is the viscus most frequently affected by metastases, 
lends weight, I think, to my belief that lymph-embolism may be 
held responsible for its participation in the malignant process 
originally beginning in the breast. 

In this place it is apposite to remark that the old theory 
of abdominal invasion being secondary to thoracic involvement 
is certainly erroneous. I have seen cases in which careful 
postmortem examination showed no thoracic lesions whatever 
and yet marked abdominal disease was present. Handley 



Carcinoma. 211 

also calls attention to this fact, and his statistics concerning the 
matter are most valuable. Thus, out of 422 cases, there were 
70 which showed abdominal metastases, but no thoracic ones. 
In many cases intrathoracic growth is also present, particularly 
enlarged glands in the mediastinum. That detachment of 
cancer cells from the secondary deposits in the liver may take 
place and result either in infection of other viscera by the blood 
stream or by direct implantation upon neighboring structures, 
is, I believe, in the light of our present knowledge, not to be 
doubted. Possibly direct growth from the surface of the liver 
to the peritoneum may lead to further involvement of the ab- 
dominal organs. 

Dissemination by the blood stream was long considered to be 
the primary factor in the dissemination of mammary carcinoma. 
Years ago when it was thought that there was a specific carci- 
nomatous virus it was customary to attribute the formation of 
secondary deposits to the transmission of this poison to the 
affected organs by the blood stream. Such a theory, how- 
ever, finds no support at present. It is maintained instead 
that cancer cells detached either from the primary or secondary 
neoplasms enter the veins and become deposited in remote parts 
of the body. It has been supposed that the morbid growth in- 
vades the veins directly, first becoming attached to the sheath and 
then gradually invading its different coats until finally it per- 
forates the intima and grows into the lumen of the vessel as a 
fungous mass from which particles are detached and swept 
away by the blood stream, to be deposited in other organs where 
they serve as foci of development for secondary neoplasms. 
As the small veins in the vicinity of the primary growth are 
often found involved in the morbid process, and as apparently 
trustworthy observations have shown the presence of these 
embolic cancerous masses in the blood-vessels between the pri- 
mary growth and secondary deposits, it is not surprising that 
credence was given to the theory of dissemination by direct 



212 Diseases of the Breast. 

invasion of the vascular system from the original focus of dis- 
ease. So, too, its invasion indirectly through the lymphatic 
system by way of the thoracic duct has been held responsible 
for the production of cancerous deposits in regions remote from 
the breast. The thoracic duct itself has been found blocked 
with cancerous masses, and of course in such a condition it is 
safe to assume that particles of the same substance would be 
transmitted to the innominate vein and thence swept onward 
by the venous current. 

That this method of dissemination may and does occur I 
do not doubt, but I am not inclined to attribute so much import- 
ance to it as has been given it by some writers. That it may be 
the means of producing remote metastases late in the course of 
the disease I am willing to admit for want of a better explanation 
of their occurrence, but there are certain weak points about the 
theory which must cast doubt upon its validity. Thus, nearly 
twenty years ago, Mr. Stephen Paget pointed out that embo- 
lism is a process which should affect all organs alike and not 
show an affinity for certain ones to the practical exclusion of 
certain others. He called attention to the fact that out of 735 
cases of mammary cancer there were metastases in the liver in 
241, whereas in only 17 were there metastases in the spleen. 
In 340 cases of pyemia, however, abscess of the liver occurred 
66 times and abscess of the spleen 39 times. Again, one would 
naturally suppose that cancerous emboli passing from the great 
veins in the neck to the right side of the heart and thence to the 
lungs would produce secondary growths in the lungs more fre- 
quently than in more remote organs. It is known, however, 
that such is not the case. Thus, in Mr. Paget's statistics, they 
were affected in only 70 out of 735 cases. Moreover, it is 
well-known that carcinoma originating in certain organs shows 
a special predilection to invade other organs with secondary 
metastases. The frequency with which the bones are affected 
in carcinoma of the breast and the prostate gland is a matter 



Carcinoma. 213 

of common knowledge, as is also their almost complete immun- 
ity in carcinoma of the stomach. 

It is apparent, therefore, that a theory of mere mechanical 
distribution is not sufficient to completely account for the for- 
mation of the various metastases. Mr. Paget was inclined 
to attribute a special predisposition of certain tissues and organs 
to the malign influence of the cancerous elements. Roger 
Williams also considers that some organs are better able to de- 
stroy the cancer emboli than others. Such explanations, how- 
ever, are merely putative, and to my mind afford no help in 
enabling a better understanding of the manner in which distant 
metastases occur. 

That cancer cells are readily destroyed by the blood has been 
recently demonstrated by M. B. Schmidt (Die Verbreitungs- 
wege der Carcinom). He has shown that the tendency of these 
foreign bodies is to excite thrombosis, with the result that the 
original nucleus, that is, the cancer embolus, is destroyed by 
contraction of the thrombus. In view of this liability of the 
cancerous emboli to be destroyed, I am of the opinion, as already 
stated, that the importance and frequency of blood-dissemina- 
tion has been overestimated. That in some cases the emboli 
survive, grow in the tissues in which they are deposited and thus 
produce secondary neoplasms, I am willing to admit, for I 
believe that such an occurrence is not only possible but probable. 
In comparison with lymphatic dissemination, however, I believe 
it to be very uncommon. In conclusion I would state that I 
am not prepared to accept as entirely satisfactory any of the 
theories of dissemination thus far advanced, for the reason that 
there are cases in which remote metastases occur which cannot 
be adequately explained by any of them. In other words I 
believe it yet remains to be shown how certain secondary 
growths originate. 

In regard to the frequency with which various organs are 
affected with secondary deposits, available statistics are not 



214 Diseases of the Breast. 

of much value because they are based upon too small series of 
cases . To be of any value in showing the comparative frequency 
with which those organs rarely involved, such as the thyroid 
gland and pancreas for instance, become affected, deductions 
should be drawn from thousands of cases, and not from a few 
hundred. INIoreover, the subject of these rare metastases is of 
no practical importance. 

Among the organs most frequently affected are the liver^ 
the pleura, the lungs, the bones, and the brain. Reference has 
already been made to involvement of the liver through the 
lymphatics, it being the viscus most commonly attacked by 
secondary deposits. 

The pleura may be infected by direct growth from the pri- 
mary neoplasm in the breast, from the mediastinum, from the 
supraclavicular glands by extension of the growth directly 
downwards through Sibson's fascia, and no doubt in cases in 
which the lungs are involved still further dissemination to the 
pleura may take place from these latter organs. That the last- 
named method of dissemination is rare, however, must be 
admitted, the pleura usually being invaded before the lungs 
are attacked. Handley found secondary nodules on the pleura 
in ^S percent of 422 cases. 

Statistics relative to the frequency of pulmonary metas- 
tases vary greatly. Thus, for example, out of 423 autopsies 
collected from various sources Gross found the lungs affected 
in 49.9 percent, whereas Handley in 422 cases found them in- 
volved in only 25 percent. These figures certainly show the 
futihty of placing reliance upon statistics based upon a small 
number of cases. 

I am inclined to attribute considerable importance to blood- 
embolism in the production of metastases in the lungs on ac- 
count of the fineness of the pulmonary capillaries. 

The frequency with which mammary carcinoma produces 
metastases in the bones is well-known. The sternum and ribs 



Carcinoma. 215 

may be invaded by direct extension of the malignant process 
from the primary neoplasrp. Attention should also be called 
to the possibility of the humerus being invaded by direct 
extension of the morbid process from the axilla. 

The weight of opinion seems to favor blood-embolism as 
being the cause of metastases in the other bones. Although 
statistics show that certain bones, such as the femur and the 
humerus, are particularly liable to be attacked, I am not inclined 
to place much faith in this supposed predilection for the reason 
that autopsies are not complete as far as examination of the 
osseous system is concerned. In life a cancerous bone may not 
produce any symptoms either subjective or objective to lead the 
patient or her medical attendant to suspect its existence, and, 
therefore, when postmortem examination is made a careful 
search for cancerous deposits in the bones is almost always 
omitted from the routine examination. As spontaneous fractures 
of the femur and humerus often occur, and thus attract attention 
to the fact that lesions may be present in the osseous system, 
it is natural that these bones should have often been considered 
the ones most subject to metastases. Certainly fracture of 
the cranial and pelvic bones and of the scapula could not be 
expected to take place even though they were much affected 
by cancerous deposits. 

A comparison of certain series of cases is very interesting 
in this respect. Thus in 336 necropsies conducted by Torok 
and Wittelshofer the cranial bones were examined in nearly 
every case, with the result that they were found diseased in 33 
cases, or 9 percent of the total number. In the combined cases 
of Munn and Williams, in which the cranial bones were exam- 
ined only when evidence of disease had been present during 
life, they were found affected in only 1.8 percent of the cases. 
Statistics recently compiled by Mr. Handley from the Alid- 
dlesex Hospital cases — 329 in number — seem to show that 
the bones nearest the primary neoplasm arc most frequently 



2i6 Diseases of the Breast. 

invaded. The clavicle, however, showed an exception to this 
rule. Moreover, I am inclined to believe that if the sternum 
and ribs were excepted, and complete examination of the other 
bones made in a large number of cases, this rule might be still 
further invalidated. As already stated, the trouble with statis- 
tics relating to such subjects as the one now under discussion 
is that they are based upon a comparatively meager series of 
cases. I cannot but believe that if routine examination of the 
radius, ulna, tibia and fibula were made in a considerable 
number of cases many new instances in which deposits were 
found in them would be added to the isolated ones now on record. 
Herbert Snow, who examined the osseous system in 12 unse- 
lected cases of mammary cancer, found fibrotic induration in the 
marrow of various bones ; and, on microscopic examination, the 
typical characteristics of scirrhus cancer were revealed. All 
these 9 cases were insidious ; no tumor of bone or fracture had 
been witnessed during life (British Medical Journal, March 
12, 1892). 

In regard to the site of the deposits in the femur and humerus 
it is interesting to note that the upper portion of the bone is 
invariably attacked. Handley states that the base of the great 
trochanter is the point where the morbid process begins in the 
femur, but that owing to the thickness of the bone there fracture 
takes place below\ With increase of the deposit pressure 
atrophy occurs, and it is this condition, no doubt, which leads 
to fracture. A free formation of callus around the fracture 
sometimes results in union of the broken ends of the bone. ^ 

The vertebrae are also affected with comparative frequency, 
deposits being found in them in 9 out of the 336 cases examiined 
postmortem by Torok and Wittelshofer. 

The brain and its membranes are also probably more com- 
monly involved by secondary deposits than they have been sup- 
posed to be. No doubt further careful examinations will prove 
this statement to be true, just as I believe they will show the 



Carcinoma. 217 

bones to be more frequently attacked than present statistics 
show them to be. 

The pelvic organs, according to available statistics, show 
disease in about 5 percent of all cases. Gross found the uterus 
invaded in 5.2 percent of the cases which he studied. In the 
cases studied by Handley metastases were present in the ovary 
in 4.8 percent of the Middlesex Hospital cases, and in 8.6 per- 
cent of the Guy's Hospital cases, that is in 5.6 percent of 
the total number. In Guy's Hospital, where the higher per- 
centage was found, the average age of the women admitted for 
cancer of the breast is considerably less than that of the Middle- 
sex Hospital, where there is award for incurable cancer patients. 
Handley is of the opinion that the greater frequency of ovarian 
metastases in the former class shows that the ovary is more 
likely to become affected before the menopause than after it, 
that is, at a time before retrograde structural changes take 
place. This theory is certainly very plausible. 

Symptoms. — The evolution of mammary cancer is very 
insidious, so that as a rule its onset is not marked by subjective 
symptoms. So slow may be the growth of the primary neoplasm 
that the patient's attention may not be attracted to it until it has 
become of considerable size, when it is discovered accidentally. 

In my experience the majority of women affected with this 
disease have sought advice merely for the reason that they have 
found a mass present in the breast, and not because the mass 
has given rise to any subjective disturbances. This absence of 
suffering in the earlier stages of the disease is a circumstance 
which cannot be too strongly impressed upon the general practi- 
tioner, who, though he sees comparatively few cases, usually 
sees them earlier than it is the good fortune of the surgeon to 
encounter them. It is equally important for the physician to 
impress upon female patients in general the folly of disregarding 
the presence of a tumor in the breast, and particularly of con- 
cealing it from relatives, friends, and the family physician. 



2i8 Diseases of the Breast. 

It is a well-known fact that women who will not delay in 
seeking advice as soon as they suspect the presence of an 
abdominal tumor, and who willingly submit to a local and even 
vaginal examination, will carry a tumor in the breast until it 
has advanced far beyond the stage of operability. Why this 
is so surpasses the bounds of human understanding. In some 
cases it may be due, for a considerable length of time at least, 
to the absence of pain and soreness so characteristic of the 
earlier stages of the disease, and as a result of which it may be 
considered of a trivial nature. At all events the importance 
of having patients consult a surgeon as soon as a neoplasm is 
discovered cannot be too strongly emphasized. 

Another explanation of this strange conduct on the part of 
women may lie in the circumstance that tumors of the breast 
are considered by the laity as synonymous with cancer and that 
cancer is believed to be the equivalent of death; and that it is 
sometimes due to a desire of a noble, self-sacrificing woman 
to suffer mutely rather than cause anguish to husband, children, 
or family. 

In still another class of women the fear of mutilation and 
disfigurement may be the motive which restrains them from 
revealing their infirmity. 

In fact, this disposition to conceal mammary tumors is so 
common in all circles of life that I have come to look upon it as 
a symptom of the disease. 

I once treated an elderly woman for a fracture of the left 
humerus; union was surprisingly slow in taking place, and 
after sufficient callus had been thrown out to make reason- 
ably good union, refracture, without traumatism, suddenly 
occurred. 

The patient having a cachectic appearance, my suspicions 
were aroused, and when I asked her if she had uterine or other 
disease she reluctantly showed me an advanced scirrhus carci- 
noma of the mamma, which she had concealed from me by re- 



Carcinoma. 219 

fusing to expose the breast when the fracture-dressings were 
apphed. 

Other women have come to me with a tumor of the breast 
which they have carried for years, saying that no one knew of it 
and requesting that I deny its existence to their nearest relatives. 
Such a case occurred in a maiden lady of about fifty-five years 
of age, the daughter of a prominent surgeon, the sister of a 
physician, both of whom she declined to consult. She came to 
my office with a married sister, but would not permit her to 
come into the consultation room during the examination. She 
presented a large tumor in the right breast which was evidently 
sarcomatous, although it was undoubtedly originally benign. 
An immediate operation was advised, and although the advice 
was accepted she did not allow her family to know her condition 
until she entered the infirmary. No local recurrence took place 
but internal metastasis eventually caused death. Metastasis 
to the right femur was plainly visible in six months. A large 
tumor also developed in Scarpa's triangle. 

A third case I saw in consultation with a former colleague 
in Louisville, Kentucky. A most intelligent maiden lady, 
about fifty years of age, a well-known teacher in the female 
high school, and the daughter of a former distinguished pro- 
fessor of surgery, consulted a surgeon for a tumor of the breast 
which she had concealed from her sister, with whom she lived, 
and to whom she was greatly attached. An engagement to 
marry caused her to seek surgical advice, and at the time of 
doing so the growth was found so far advanced as to be well- 
nigh inoperable. 

I could mention other cases where the concealment has been 
practised, but these are sufficient to serve as illustrations. 
Similar cases have been reported by other writers, notably by 
Mr. Sheild, of London. 

Cancer of the breast begins as a small nodule, usually, though 
not always situated in the upper outer quadrant of the gland. 



220 Diseases of the Breast. 

It gradually increases in size, is adherent to the gland, and is 
freely movable with the latter. It cannot, as a rule, be isolated, 
for the reason that it is intimately connected with the glandular 
parenchyma. It is hard and firm in consistency, and can be 
readily palpated, although as just stated no distinct line of 
demarcation between healthy and diseased tissue permits it to 
be distinctly isolated. This diffuse nature is distinctive of car- 
cinoma. As the morbid process advances the tumor becomes 
adherent to the skin in front and to the pectoral fascia behind. 
The skin loses its smoothness and softness and becomes slightly 
corrugated. This corrugation is particularly noticeable when 
the skin is picked up between thumb and finger and slightly 
compressed. This appearance of the skin has been likened by 
French writers to that of orange peel, and the comparison is one 
which is not at all inappropriate. 

If the neoplasm is situated near the center of the gland, retrac- 
tion of the nipple may take place, owing to traction on the fibrous 
bands which connect it with the deeper portions of the gland. 
Gross observed this phenomenon in io8 out of 207 cases, or in 
a little more than 50 percent. Thus it is seen that the sign is 
far from constant, so that too much dependence must not be 
placed upon it. It was formerly considered one of the cardinal 
signs of malignancy, but we now know that such is not the case 
(see Fig. 29). 

Later in the course of the disease firm fixation of the breast 
to the pectoral fascia occurs, or the substance of the muscle 
itself becomes invaded. If the arm be abducted so as to put 
the oectoral muscles on the stretch, it will be found that the 
breast will not move in the direction of the muscle-fibers ; when 
the arm is adducted again so that the muscles are relaxed, 
the breast then moves with them. At an earlier stage of adher- 
ence partial fixation to the deep fascia may be demonstrated 
by abducting the arm and then moving the breast up and down 
and from side to side with one hand while the elbow is held 



Carcinoma. 



221 



with the other and the patient makes an effort to carry her 
arm to the side of the body. During these manipulations it 
can be readily determined whether the mobility of the gland is 
diminished. 




Fig. 29. — Scirrhus carcinoma. Note retraction of the nipple. 



Women presenting all these signs may feel perfectly well 
and look strong and healthy, a circumstance which goes far to 
prove that mammary cancer per se is a strictly local affection. 



222 



Diseases of the Breast. 



Adherence of the skin may in time be followed by ulceration, 
but as a rule the latter occurs late in the course of the disease. 

Dissemination of the cancer virus through the lymphatics 
undoubtedly begins at a comparatively early period in the evo- 




Fig. 30.— Typical scirrhus carcinoma of the upper and inner quadrant of the breast. 



lution of the neoplasm, with the result that the lymph glands, 
which receive lymph from the channels passing through the 
breast, become diseased. Those in the axilla usually first 
show signs of involvement, and then those in the subclavian 



Carcinoma. 223 

triangle. In a patient whom I recently operated upon two en- 
larged glands were found between the pectoral muscles. This 
was the first case in which I had observed enlargement of these 
glands, although I had read of instances in which they had 
been found (Rotter, Grossmann). 

In regard to the exact time at which glandular involvement 
occurs, it may be stated that statistics show that palpable 
enlargement may be demonstrated between the eleventh and 
eighteenth months. Such statistics are of very little, if any, 
value for the reason that glands may be diseased and still not 
be perceptibly enlarged. Much^credit is due to Gross, Banks, 
Gussenbauer, Kermisson, and a number of other surgeons 
who first called attention to this fact. It is a matter which the 
general practitioner should not fail to remember. By bearing 
it in mind he may be led to refer cases to the surgeon which 
otherwise he might keep under observation for a longer period, 
to the manifest detriment of the patient. 

Bull's statistics show that 65 percent of all patients present 
signs of palpable enlargement of the axillary glands when first 
seen by the surgeon, and I believe it would be safe to say 
that even a higher percentage are thus affected, as at operation, 
however early it may be performed, there will almost invariably 
be found metastases to the lymph nodes. In but a single case 
have I failed to demonstrate it. 

The glands which first become palpably enlarged are, as a 
rule, those along the external margin of the great pectoral 
muscle. They may be readily felt by insinuating the finger- 
tips beneath the lower portion of the anterior axillary wall and 
running them up and down along the borders of the muscle. 

As the disease makes greater and greater inroads the local 
condition becomes much more appalling in appearance. As 
already stated ulceration frequently follows adherence to the 
skin. The tumor becomes livid and purple, the veins dilated, 
the skin perforated, and a fissure forms which becomes larger 



224 Diseases of the Breast. 

and larger, its edges become everted and somewhat under- 
mined, although their base is hard and firm. From this sur- 
face a purulent, malodorous discharge is given off, and as the 
ulcerative process encroaches more and more upon the con- 
tiguous areas of the breast, hemorrhages may occur, owing to 
erosion of the vessels. Though usually slight they may occa- 
sionally be so severe as to alarm both patient and physician. 
The ulcerative process may also extend to the axilla. In ad- 
dition to these ulcerative changes in the breast and axilla 
subcutaneous cancer nodules may be present in various por- 
tions of the thoracic wall, in some cases being confined to 
the regions adjoining the breast, in others extending over a wide 
area. They have been known to invade the shoulder, the back, 
and the abdomen ; they not uncommonly undergo ulceration in 
these remote areas, but as a rule it is those near the primary 
neoplasm which show this change. 

With the supervention of these extensive local disturbances 
the general health manifests signs of impairment. The patient 
loses flesh and strength, and enters upon a decline which has an 
invariably fatal progression. The ulceration becomes more 
extensive, the secretion more abundant, the hemorrhages more 
frequent and more profuse. Owing to compression of the 
axillary v^in edema of the upper extremity may supervene, 
although this symptom is not very frequent. I doubt if I 
have observed it in miore than 5 percent of my late cases. 
The cachectic appearance and extreme emaciation presented 
by the unfortunate subjects of advanced cancer is so well- 
known that it would be futile to portray it in detail. Happily 
they are not seen as often now-a-days as they were in the past. 
Before death puts an end to the suffering of these patients 
signs of generalization of their disease usually plainly manifest 
themselves. Thus nodules in the liver or uterus may be palpated, 
spontaneous fractures occur, or signs of pulmonary mxctastases 
break out. Pleural effusion may occur, although in my expe- 



PLATE XXXVI 




*» 



'^Mfitf' 




Large fu-ntratinsr oarcinoina of the breast. 



Carcinoma. 225 

rience it is one of the rarest complications. Allusion has 
already been made to the occurrence of paraplegia, owing to 
dissemination of the disease to the spinal column by way of 
the lymphatics. This is a late symptom also, and one which 
I have not often seen. 

There is considerable difference in the mode of evolution and 
duration of the various forms of cancer of the breast, and al- 
though these differences have been described under pathology 
it may not be amiss to say something concerning them here, and 
particularly to call attention to the rare, so-called acute form of 
cancer. 

Thus it is apparent that ulceration will take place earlier 
in the encephaloid forms than in scirrhus, in which the ten- 
dency to contraction is so great. It is in ulcerating carcino- 
mata of this form that fungous masses, such as are shown in 
Plate XXXVI, develop. Naturally such a tumor will destroy 
life in a shorter time than will ordinary scirrhus. 

The tendency to early ulceration in adenocarcinoma has 
already been alluded to. 

The slow progress which atrophic scirrhus makes has al- 
ready been mentioned under pathology. The most marked 
characteristic of this form is its invariable tendency to produce 
contraction of the tissues. It often produces a decided de- 
pression of the surface of the breast, so great is the contraction 
of the tissues beneath. In fact the breast affected is much 
smaller than its fellow. In a case recently operated upon 
the cancerous breast was less than half the size of the healthy 
mamma. The nipple may be so retracted as to be scarcely per- 
ceptible. Ulceration occurs only after years, if indeed it happen 
at all. Despite the slow evolution of the malignant process, 
it is always progressive. Patients may live for ten, twelve, 
or fifteen years, however, before they succumb. It may be 
well to emphasize in this place the fallacy of allowing patients 
affected with this form of mammary cancer to go on from 
15 



226 



Diseases of the Breast. 



year to year without operation. The slowness of its growth 
and its comparative benignity constitute good reasons for suc- 
cessful removal of the affected tissues and the eradication of 




Fig. 31. — Atrophic or withering scirrhus. Observe the complete disappear- 
ance of the nipple and shrinkage of the breast. 



the morbific elements which spread therefrom. It is cer- 
tainly reprehensible not to operate in cases of this kind as soon 
as the diagnosis is made. (See Fig. 31.) 
The so-called acute cancer which has been described by 



Carcinoma. 



227 



Billroth, Volkmann, Paget, Gross and a few later writers, 
notably Delbet, may destroy life within a few months after its 
onset. This form of the disease, which is fortunately rare, 
often begins during pregnancy or lactation and so rapidly 
involves the entire gland that it may well be referred to as car- 
cinomatous mastitis, as suggested by Volkmann. The affected 



Jflf 



V^ 



X 



Fig. 32. — Advanced carcinoma. 



breast begins to increase in size without any subjective dis- 
turbances being experienced by the patient. The enlargement 
is diffuse in contradistinction to that which characterizes the 
ordinary forms of mammary cancer; consequently upon palpa- 
tion no distinct mass can be outlined in the breast, the organ 
being enlarged in its entirety and being firm and hard to the 
touch. The skin soon becomes reddened and adherent, and ul- 



228 



Diseases of the Breast. 



ceration quickly supervenes. Pronounced cachexia early mani- 
fests itself, and the patient dies from exhaustion or possibly 
from repeated hemorrhage from the ulcerated areas of the breast. 
Remarkable instances in which both breasts have been attacked 
have been reported. One of the most interesting cases of this 
kind which I have found is one reported by Billroth. It was 




Fig. t,^. — Inoperable carcinoma. 



that of a lady who was attacked five weeks before delivery of 
her eighth child, and who died seven days after an easy and 
natural labor. Postmortem examination revealed metastases 
in the hver, kidneys, omentum, thyroid gland, and pericardium. 
Both breasts were enormously enlarged, although the entire 



c 



arcinoma. 



229 



duration of the disease as noticed by the patient was only six 
weeks. 

Another interesting case observed by the late S. W. Gross, 
and also affecting a pregnant woman, was one in which the 
disease apparently began as a nodule in the sternal portion of 
the mamma, and then within two weeks had diffused itself 




Fig. 34. — Inoperable carcinoma. Showing enlarged glands in right axilla in 
left sided mammary disease. 

throughout the substance of the gland. Gross, who saw the 
patient three months after the first manifestations of her disease, 
found the breast firmly adherent to the chest- wall; the skin adhe- 
rent to the breast, and thick, hard and brawny; the axillary 



230 Diseases of the Breast. 

glands extensively diseased, and the supraclavicular glands also 
involved. 

This case seems to indicate that the disease may occasionally 
at least be discrete in its inception, but even though this cir- 
cumstance be correct it is not important, for the reason that 
the progress of the disease is so rapid that it soon assumes a 
diffuse character. 

In a case reported by Klotz the patient succumbed three 
months after the onset of the disease; and in another recorded 
by Schmidt six months after its beginning. 

Although frequently associated with pregnancy and lacta- 
tion, acute mammary carcinoma may develop independently 
thereof. Thus, of four cases which have come under the obser- 
vation of Delbet, two occurred irrespective of pregnancy, one 
during pregnancy, and one during lactation. Schmidt also 
observed a case in a non-pregnant and non-lactating woman. 

The peculiar mode of onset and evolution of this form of 
mammary carcinoma together with its rarity, has very naturally 
resulted in its being mistaken for other diseases, particularly 
abscess and sarcoma. Of course, as it progresses, differentiation 
from abscess can be readily made, but distinction from sarcoma 
is not so easy. In view of its rapidly fatal course every case in 
which its presence is suspected should be considered operative 
and at once referred to the surgeon. 

The clinical aspect of cancer en cuirasse, a form the path- 
ology of which has already been discussed sufficiently to im- 
part a fair idea of the ravages which it may produce, is one of 
the most terrible afforded by any variety of cancerous disease to 
which the mammary gland is subject. 

Velpeau, who gave the first accurate description of this 
variety of the disease in the year 1838, related the case of a 
lady whose suffering was so great that she begged to be given 
a poisonous dose of opium that she might be relieved of her 
misery by death. Cases equally distressing have been ob- 



PLATE XXXVII 




Cancer en cuirasse. 



Carcinoma. 231 

served since by many surgeons whose experience with the dis- 
ease has been considerable. 

In some instances the lesions affecting the thoracic wall may 
appear before any tumor in the breast has been detected, but as 
a rule there is a mammary neoplasm present before the changes 
in the skin over the mammary and pectoral regions manifest 
themselves. They may also first appear after the diseased 
breast has been removed. That these variations in the onset of 
the disease exist, will not be confusing if the pathology be borne 
in mind, particularly Handley's theory of permeation through 
the deep fascial lymphatic plexus; and, likewise, if individual 
differences in the power of resistance to disease be considered. 

Whatever may be its chronological relation to the mammary 
neoplasm, the first manifestations of the disease make their 
appearance as red spots in the skin over or near one or both 
breasts. These spots gradually thicken until they become con- 
verted into disc-hke nodules, varying in size from a pinhead to 
a filbert. As ordinarily observed in the earlier stages of 
the malady they are about the size of a split pea or a coffee 
bean. It is not unusual for them to give rise to an itching 
or burning sensation as they continue to enlarge. As a result 
of the scratching and rubbing resorted to by the patient to re- 
lieve these sensations eczema may be found associated with the 
lenticular lesions. 

Some of these thickened spots may be distinctly elevated, 
so that they resemble tubercles; others, however, may be de- 
pressed. 

There is a tendency for the discrete lesions to become con- 
fluent, the nodules becoming aggregated into patches, or some 
being arranged in linear series. Pari passii with these changes 
there occurs a dense, brawny infiltration of the remaining mam- 
mary and adjoining tissues, which may extend upwards as high 
as the clavicle, downwards onto the abdominal wall, and later- 
ally as far as the posterior margin of the axilla. The veins be- 



232 Diseases of the Breast. 

come dilated, areas of melanotic deposit are formed, and in 
some cases pearl-like miliarj^ bodies are observed here and 
there over the affected surface. 

The infiltrated tissues may assume a dusky or even a brown 
hue. Velpeau compared the skin thus affected to leather, and 
Erichsen, who had observed certain portions of the infiltrated 
areas covered with crusts, likened it to the bark of a tree. 

It is stated that ulceration may also occur, and hemor- 
rhages of varying degree have resulted from erosion of super- 
ficial blood-vessels. In the many cases I have seen ulceration 
has rarely if ever been observed. 

In regard to the age incidence of this form of cancer I find 
that it may affect women at all periods of hfe. Concerning 
its predilection for the dark-skinned I have not been able to 
obtain any information. I am inclined to consider it merely 
fortuitous that nearly all my o^vn patients were brunettes. 

Almost always there is great swelling of the upper extremity, 
which gives rise to much pain. The most distressing symptom, 
however, is the compression of the thorax produced by the super- 
jacent infiltrated tissues. This compression may not only be 
so great as to interfere with the ordinary movements of the chest 
and arms, but also to impede respiration, fastening the unfort- 
unate patient in a vice, so to speak. 

The extension of the malignant process is in some cases 
very rapid, as, for example, in one reported by Esmarch, in 
which its progress was so rapid on portions of the chest as to re- 
mind one of lymphangitis or erysipelas. Such a mode of ex 
tension, however, must be unusual. As a rule the disease ad- 
vances at a moderate rate, although it usually destroys life 
within twelve or eighteen months. I know of one case in which 
the patient lived two years and a half after first noticing the 
disease. 

The very nature of this aft'ection unfortunately renders 
operative treatment futile. In those of my cases which came 



PLATE XXXVIll 





'f* 




Cancer en cuirasse. Observe recurrence in 
the cicatrix and the nodule above the chivicit:. 



PLATE XXXIX. 




Inoperable carcinoma. Large fungaiing niass 



Carcinoma. 235 

to autopsy internal metastases were invariably present in ad- 
dition to the extensive superficial cancerous lesions. 

Diagnosis and Prognosis. — As I have pointed out on several 
occasions, whatever better results may be obtained from the 
operative treatment of mammary carcinoma will depend upon 
earlier and more accurate diagnosis rather than upon improve- 
ments in technique or more extensive procedures. 

If the general practitioner, who as a rule first sees the cases, 
could be taught to remember that 80 percent of all mammary 
neoplasms are malignant, and also be prevailed upon to forget 
the erroneous teaching of a past era relative to the hopelessness 
of mammary carcinoma, there is not the slightest doubt that the 
percentage of radical cures by operation would be increased 
materially during the next few years. It is desirable, as Sir 
William Banks pointed out nearly thirty years ago, to operate 
on a cancer of the breast when it is no larger than a pea, if 
patients would apply to us at that time or if diagnosis could be 
made. Unfortunately this teaching failed to fall upon fertile 
soil, and the family physician, and even the consulting intern- 
ist, have continued to distribute that death-dealing advice 
^'wait and see if it is malignant." Worse than this they have 
complacently continued to advise against operation even after 
the malignant nature of the disease has manifested itself in 
unmistakable signs, in the meantime repeatedly plastering the 
affected breast with antiphlogistine, ichthyol, or belladonna 
ointment. 

This lack of faith in the power of surgery to cure is not so 
much to be wondered at in view of the teachings formerly pro- 
mulgated by many surgeons of repute. The pity is that the 
work of modern investigators and operators has not been more 
closely followed. Rarely a month passes that the unfortunate 
experience and still more regrettable teachings of a late illustri- 
ous professor of surgery in Philadelphia are not quoted to me 
by some of his pupils. It seems exceedingly strange, however, 



236 



Diseases of the Breast. 



that the more advanced and better teaching of an equally illus- 
trious contemporary is not more generally remembered, for it was 
through him that the complete operation and teachings of Aloore, 
of London, were first practised and inculcated in America. 

My statistics based on 5 ,000 cases show that in any given case of 
mammary neoplasm the chances are more than 5 to i in favor 




Fig. 35. — Recurrent carcinoma. 



of mahgnancy. If conditions were reversed, and the chances 
only I in 5 in favor of malignancy, the dilly-dally policy so 
often adopted could only be justified on the ground that a sur- 
gical operation promising relief is more dangerous to life than 
the disease itself. But such is not the case. My statistics 
based on 2133 operations performed since 1893, by twenty-one 
American surgeons, show the operative deaths to be less than i 



PLATE XL. 




Recurrent carcinoma. Observe edema of the arm. Interscapulo- 
thoracic amputation was performed. 



PLATE XLI. 




Patient shown in Plate XL after interscapulo-thoracic amputation 
had been performed. 



Carcinoma. 241 

percent. In view of the fact that all malignant disease untreated 
by surgical means must sooner or later end in death, this slight 
mortality following operation is scarcely to be considered. 
What consistency, I ask, is there in advising a woman with a 
small ovarian cyst or myoma of the uterus — neither of which 
has a tendency per se to shorten, much less to terminate life — to 
travel hundreds of miles that a specialist may do a laparotomy, 
and the same day, perhaps, admonish her sister or friend with a 
mammary tumor that she must calmly and resignedly await a 
lingering, painful and loathsome death, rather than submit to a 
less dangerous operation curing permanently all benign growths 
and at least one-third of the malignant ones? 

Certainly none whatsoever, and it is worse than folly to adopt 
such a course. The first class of cases are operated on largely 
for convenience, such as relief of pain, mental anxiety, deform- 
ity, and possible danger to life by accident. They should 
be operated by all means, but are, as I have said, largely 
operations of election; whereas a tumor of the breast being 
very generally malignant should demand an immediate opera- 
tion to save life itself. The fault is, in part at least, a divided 
one, falling somewhat upon the patient as well as the doctor, 
owing to the tendency, already mentioned under symptomat- 
ology, which women show to conceal a growth in the breast. 

After these preliminary considerations, the importance 
of which I cannot lay too much stress upon, it is my purpose to 
explain as best I can the manner in which mammary carci- 
noma may be the most certainly recognized, and to contrast its 
manifestations with those of other diseases of the breast with 
which it may be confounded. 

The article on symptomatology has, I trust, portrayed the 
general aspect of the disease. Here I shall refer to and elabor- 
ate those symptoms and signs which are the most distinctive. 

The method of examining a patient in whom a mammary 

neoplasm is suspected is most important. It is always neces- 
16 



242 • Diseases of the Breast. 

sary to have the patient remove all clothing covering the thorax, 
so that thorough inspection of both breasts can be made and 
any asymmetry, either natural or acquired, noted. Most of 
the v^omen I have examined have, unless otherwise requested, 
merely loosened their clothing sufficiently to expose the afTected 
breast. It is my custom at present to ask them at once to pre- 
pare for a thorough examination of the entire thoracic region. 

This enables the surgeon to examine the axillae, the supra- 
clavicular region, and the opposite breast, as v^ell as the one of 
which the patient complains ; and also to detect at once any in- 
volvement of the integument over the lateral thoracic walls or 
epigastric region. 

In cases much advanced the thorax should be carefully 
percussed and auscultated for evidences of pleurisy, and the 
liver examined, to determine, if possible, the presence of cancer- 
ous nodules. The respirations should be counted, and if at 
all increased in frequency, inquiry should be made in regard to 
the existence of dyspnea. 

All portions of the breast should be examined, the tissues 
being not merely picked up between thumb and fingers, but 
the flat of the four fingers being passed over every portion of 
the gland, so that differences in hardness, contour and mobility 
may be the better determined. In this manner the firm, in- 
durated, ill-defined mass characteristic of beginning or early 
carcinoma may be accurately made out. 

In fat women this method of examination will not yield 
satisfactory results as readily as it will in those who are thin- 
ner. In the former class a scirrhus growth of considerable 
size may produce simply a dimpling or puckering of the skin 
over it, and exceedingly deep palpation with thumb and fingers 
will be necessary to detect any induration in the gland itself. 

The location of a tumor is of considerable significance from 
a diagnostic standpoint, malignant growths being most common 
in the upper and outer quadrant, lower or axillary quadrant, and 



PLATE XLII. 




°>1.^ 



Sternal symptom. {Herbert Siioio.) 



Carcinoma. 245 

behind the nipple. Benign growths on the contrary are most 
frequently found in the upper and inner quadrant or sternal 
half of the gland. When situated beneath the nipple, it is to be 
remembered that they produce contraction of this structure, a 
phenomenon which is an important diagnostic sign. Its absence, 
however, must not be misconstrued in favor of benignity, for 
the sign will not be caused by tumors remotely situated from 
the nipple. 

The location of the neoplasm is also of some importance in 
regard to the distribution of metastases. Thus a tumor in 
the upper hemisphere is more likely to cause early involvement 
of the supraclavicular glands, while one in the inner hem- 
isphere predisposes, I believe, to infection of the mediastinal 
glands. 

The sternal symptom of Snow has already been alluded to 
in this latter connection. It will, of course, be present only 
in advanced cases. Indeed, I have rarely seen it. (See 
Plate XLII.) 

In regard to subjective symptoms, it is important first of all 
to bear in mind that the onset, as a rule, is not marked by 
any suffering. Contrary to the popular opinion and one, too, 
which I am sorry to state still continues to be shared by many 
members of the medical profession, mammary carcinoma may 
attain a well-advanced degree of development before it produces 
any pain. It is only when the tumor attains considerable size 
or compresses nerve-trunks — either of itself or through its as- 
sociated glandular involvement — that a sense of heaviness and 
weight in the first instance and of lancinating pains radiating 
to the arm, shoulder and back, in the second, will be experi- 
enced. Adhesion of the tumor to the skin may also give rise 
to pain, and ulceration naturally causes much suffering. 

I have rarely seen a case in which the slight twinge or pang 
like the prick of a needle was experienced around the thorax or 
down the arm very early in the course of the disease, although 



246 Diseases of the Breast. 

this is a symptom upon which ]Mr. Sheild places considerable 
dependence. The late S. W. Gross also believed it to be a 
valuable sign. 

Pain when present is almost always of a neuralgic or inter- 
mittent character, and I have observed in many cases that it is 
much worse in damp weather. Another point of importance is 
that the carcinomatous breast is rarely painful to manipulation. 

In advanced cases associated with edema of the upper arm, 
there is also much pain experienced, but the associated phe- 
nomena of the disease w^hen it has reached such a stage are so 
distinctive as to render the trouble in the arm insignificant 
from a diagnostic standpoint. The same is true of the girdle 
pain which occurs in cancer en cuirasse. In the comparatively 
rarer forms of the disease, such as acute cancer and cancer 
cysts, the symptoms and signs are likewise so pronounced that 
they overshadow pain and tenderness, which at best are insig- 
nificant in any form of the disease so far as their diagnostic 
value is concerned. 

It is timely that physicians should realize this fact and 
more frequently combat and endeavor to dispel the erroneous 
idea generally entertained by women that because a growth 
is painless it is not dangerous. A woman often remarks to me 
with evident surprise that she can hardly believe a tumor is 
cancerous because it has never hurt her, and this despite the 
fact that there is a decided tendency among women to regard 
all tumors in the breast as cancers. 

Age is without doubt one of the most valuable guides, as 
carcinoma is by far most common after the fortieth year, when 
the functional activity of the breast is ceding to retrograde 
changes or when such changes have already become estab- 
lished. It has already been pointed out under symptomatology, 
that young women are far from exempt, and therefore the pres- 
ence of an othenvise suspicious growth in the breast should not 
lead one to discard the opinion that it may be carcinoma merely 



Carcinoma. 247 

because the patient happens to be young in years. My 
statistics, based upon 5,000 cases, show that 9 percent occurred 
in women between the ages of twenty and thirty, and 11. 5 
percent between the ages of thirty and forty. These figures 
certainly show the folly of dismissing from consideration the 
possibility of a growth being malignant merely because it affects 
the breast of a young woman. It is true that the majority 
of hard tumors of the breast occurring in women under thirty 
are of the fibro-epithelial group of benign neoplasms, but still, 
in view of the considerable percentage of carcinomata oc- 
curring in young women, the possibility of a tumor being car- 
cinomatous must be reckoned with. 

In doubtful cases of this kind, and also particularly in cases 
where it is difficult to differentiate between carcinoma and 
chronic mastitis (abnormal involution), the microscopic test 
is a most valuable means of diagnosis. Instead of making, 
as many advise, an incision into the growth for diagnostic pur- 
poses, and then closing the wound — a practice not altogether 
satisfactory, and certainly not free from danger — I prepare for 
and get the consent of the patient for a complete operation. 

A competent microscopist is present with his apparatus, 
prepared for rapid yet accurate work. If the chances strongly 
favor benignity, the tumor and its capsule only are removed 
and submitted for an immediate examination and opinion. 

Usually in less than ten minutes the report is returned. If 
there is a strong suspicion of malignancy, a portion of the 
growth near the center is removed, the wound at once plugged 
with gauze and nothing further done until the pathologist re- 
ports. If the piece thus removed proves malignant, the com- 
plete operation is immediately performed. I have followed this 
practice for fourteen years and have never known a mistake to 
be made in diagnosis, nor have been made to suspect that harm 
had resulted from the liberation of cancer cells which aft'ected 
adjacent healthy tissue. I think, however, that the wound 



248 Diseases of the Breast. 

thus treated should be left entirely alone until the breast and 
the muscles have been removed. Therefore, it would seem 
that the danger can be minimized if not actually prevented, 
and the slight risk incurred is as nothing to the definite infor- 
mation gained. I can point to women, happily married and 
with practically perfect breasts, where everything might have, 
probably would have, been different had not this precaution 
been taken in operations for benign growths before marriage. 
Further, I have been prevented from mistakes in at least six 
malignant tumors. 

When operating apart from a well-appointed hospital and 
its pathologist, the macroscopic appearance of the tumor, its 
color, consistence, resistance to the knife, and, above all, the 
presence or absence of a capsule, will as a rule prevent a mis- 
take in diagnosis. Stiles's nitric-acid test may be applied to 
the tumor with advantage. Every growth removed from the 
mammary gland should, of course, be examined with the mi- 
croscope as soon as practicable. 

The history of trauma, mastitis, and discharge from the 
nipple is of little, if any, value, as it is about as commonly 
obtained in benign growths as in malignant ones. The same 
is true in regard to the social condition of the patient, for the 
reason that carcinoma is frequent enough in women w^ho have 
never borne children to render the diagnostic value of a history 
of parturition and lactation relatively unimportant. In any 
large series of cases there is found a certain percentage in which 
these etiological factors can be excluded. 

It is the same in regard to heredity. Although I believe 
a peculiar predisposition to carcinoma may be inherited, the 
absence of a history in parents, grandparents or other relatives 
should not be taken into account when there are good reasons 
for thinking a tumor is malignant. A positive family history is 
of course to be regarded as strengthening the probability of 
malignancy. A negative history, however, does not weaken 



Carcinoma. 249 

the likelihood of malignancy, provided that other circumstances 
point to it. 

In regard to differential diagnosis, the principal conditions 
from which carcinoma is to be distinguished are benign 
tumors, chronic mastitis or abnormal involution, tubercu- 
losis, sarcoma, and cysts. 

The tumors of the fibro-epithelial group, with the exception 
of the papillary cystadenoma, will as a rule present no diffi- 
culties of diagnosis. Their usual location in the sternal half 
of the gland, their distinct encapsulation, the absence of axillary 
involvement, their slow growth and their usual occurrence in 
young women render their recognition easy, as a rule. When- 
ever doubt exists the microscopic method above described 
should be employed. The papillary cystadenoma is hardly 
likely to be mistaken for carcinoma, although it may undergo 
carcinomatous degeneration in its later stages. Macroscopic- 
ally it resembles sarcoma rather than carcinoma. 

Differential diagnosis from chronic mastitis or abnormal 
involution may be impossible without the aid of the microscope. 
In those cases in which the chronic inflammatory process per- 
sists as a rehc of acute disease the liability to confusion with 
carcinoma is not so great as it is in those in which the disease 
more truly represents an abnormal process of involution. Some 
cases also develop rapidly with pain and swelling, and naturally 
would not be mistaken for any of the ordinary forms of carci- 
noma. From acute cancer they differ in that marked glandu- 
lar involvement, rapid progression to ulceration, and profound 
constitutional disturbances are absent. 

In nearly all cases of abnormal involution pain of varying 
degree is a prominent symptom. This pain, too, is frequently 
worse at the menstrual period. Thus a condition rarely 
if ever present in early carcinoma is very constant in chronic 
mastitis. It is those cases in which pain is absent that are 
most difficult to distinguish from beginning cancer. 



250 Diseases of the Breast. 

In the discrete form of tuberculosis areas of induration will 
be found in various parts of the breast, and in some cases they 
can be distinctly separated from the surrounding tissues. This 
condition is never found in carcinoma. In both varieties of 
tuberculosis — the discrete and the confluent^he earlier involve- 
ment of the axillary lymphatic glands, their more rapid growth, 
and the not uncommon development of suppuration will afford 
a valuable differential diagnostic sign. Later in the course 
of the disease fistulse, tlu*ough which the contents of tuberculous 
abscesses are discharged, may be found over various portions 
of the breast. In advanced carcinoma ulcerations rather than 
fistula communicating with the parenchyma of the gland are 
present. 

Finally, it is to be remembered that in mammary tuberculosis, 
the lesions can often be demonstrated in other organs of the 
body. 

Syphilis should not present difficulties of diagnosis when ap- 
pearing as a primary lesion or as gummata, although the latter 
have sometimes been mistaken for malignant neoplasms. As 
a rule evidences of syphilis will be found in other parts of the 
body. Gummata have a marked tendency to soften if left un- 
treated, and as this softening develops it imparts an elastic 
feeling to the mass upon palpation. When softening has pro- 
gressed to such an extent as to cause breaking down of the mass, 
the resulting ulcer is decidedly excavated and^sharply defined 
in contradistinction to the more irregular ulceration of car- 
cinoma. Even after a gumma has sloughed there may be 
practically no involvement of the axillary lymph-nodes. An- 
other dift'erence between gumma and carcinoma is that the 
former may attain a large size before becoming adherent to 
the skin. In such cases, however, the skin will often be found 
slightly discolored. 

The diffuse form of syphilis, which resembles chronic mas- 
titis, may, like that aff'ection, be mistaken for scirrhus, and in ab- 



Carcinoma. 251 

sence of history or evidence of syphilis be quite impossible to 
diagnosticate. The microscope may be required to prove that 
the disease is not carcinoma, and even then its true nature 
may fail to be revealed, as there is nothing characteristic of 
this form of fibrosis. 

Finally, it must be borne in mind that large doses of the io- 
dides cause a rapid change for the better in late syphilis of the 
breast as in like lesions of other organs. Cases have been 
reported in which large gummata almost completely disappeared 
within a week after the use of this remedy was begun. In sus- 
picious cases this therapeutic test should always be tried. 

To the experienced surgeon sarcoma will present few diffi- 
culties of diagnosis from carcinoma, and even to those who see 
but comparatively few cases of mammary disease differentiation 
should not be difficult. Their possible encapsulation, their rapid 
growth, and the circumstances that they do not become adher- 
ent to the skin or retromammary tissues constitute important 
diagnostic differences. Involvement of the lymphatic glands 
in the axilla is also rare in sarcoma and constant in carcinoma. 
When it does occur in the former the glands do not present that 
fused, matted characteristic which is invariable in the latter. 
When sarcoma becomes large the veins in the overlying skin 
become much distended, and thus furnish a sign which is not 
present in carcinoma. Finally, when the stage of ulceration is 
reached the protrusion of fungous sarcomatous masses will 
make the nature of the disease apparent. It has always been 
customary to state that sarcomata occur most frequently in 
women who have not reached middle life, and to consider their 
supposed predilection for those young in years as a diagnostic 
sign of value. My statistics, however, show that more cases 
occur in elderly than in young women. Hence it would seem 
that age incidence is not so important as it has been considered 
to be. 

Cysts have frequently been mistaken for carcinoma and 



252 Diseases of the Breast. 

their true nature revealed only at the time of operation. 
Although cysts of any material size usually impart a sensation 
of elasticity to the palpating fingers, there is a small percentage 
in which this attribute is wanting, as a result of which they 
have been erroneously thought to be cancers, particularly 
in those cases in w^hich they have occurred in the breasts of 
elderly women. The circumstance that suppuration of the 
cyst contents has led to some enlargement of the axillary nodes 
in many of these cases has strengthened the supposition that 
this disease was carcinomatous. Of course, in those cases 
in which the suspicion of a cyst is present, aspiration will set- 
tle the question. 

The involution cysts are the ones which give rise to most 
difficulty, and as they may terminate in carcinomatous degen- 
eration their recognition becomes the more important. 

I am of the opinion that in the majority of these cases the 
microscope will be required to differentiate between simple 
abnormal involution, involution cysts, and beginning carcinoma. 

The more serious of these conditions cannot be separated 
clinically from simple abnormal involution, and the small cysts 
are so compressed by the fibrous tissue in the breast that they 
may readily escape detection until the knife has laid them bare. 
Several portions of the gland should always be turned over to 
the pathologist, so that a thorough examination can be made. 

Under the microscope differences are seen which cannot be 
detected macroscopically. Thus it can be learned whether 
the epithelium is proliferating, whether minute papillary out- 
growths from the cyst-wall are present, or whether the cysts 
represent merely a dilatation of the ducts and acini. Cancerous 
change can, of course, be detected in 'this manner when it is 
present. 

Adenocarcinoma is to be differentiated from the adenomata 
by its tendency to infiltrate, its larger size, its constant, steady 
growth which finally terminates in ulceration, and microscop- 



Carcinoma. 253 

ically by the atypical formation of the acini, combined with the 
great thickness of the walls and the breaking of the epithelium 
through the basement membrane. 

Prognosis. — Untreated, cancer of the breast will almost 
invariably result in the destruction of the patient within three 
years. The percentage of patients living after this time is so 
small that it may practically be disregarded. That the disease 
is strictly local in its beginning, and therefore amenable to 
early and radical surgical treatment, is a fact which I wish most 
strongly to emphasize. 

At the present day it hardly need be said that the earlier 
the operation can be performed the greater are the chances of 
recovery. This fact was well attested by the statistics of some 
of the older surgeons whose observations were recorded before 
the more thorough methods of operating had come into vogue. 
Thus, Winniwarter found the average duration of life after 
operation, in cases in which the operation was done before 
gross involvement of the axillary or supraclavicular glands had 
occurred, to be 22 months; whereas in those in which such 
glandular involvement had taken place it was only 13 months. 
Naturally much depends upon the thoroughness with w^hich the 
diseased structures are removed. It is most gratifying to note 
the greater percentage of patients who remain free at the end 
of three years since the extensive operative methods practised 
by Halsted, Meyer, Rotter, Stiles, Warren, Lennander, myself 
and others have come to be more generally employed. Although 
the results obtained by different operators show considerable 
variation, the highest percentage of cases remaining free from 
recurrence at the end of three years is attained by those surgeons 
who do the complete operation. This is a percentage varying 
from 40 to 50, and should serve as a conclusive argument in 
favor of the extensive removal of all accessible tissue which 
can possibly be diseased. 

This estimate coincides with the statistics of Maro-trraff, 



254 Diseases of the Breast. 

compiled independently of any material upon which I based 
my opinion. In his Wurzburg dissertation, 1904, he analyzed 
860 cases and found that recurrence took place in 430. The 
longest period of immunity in these cases was 11 years. 

Other series of cases, however, do not show such favorable 
results, the percentage of freedom from recurrence at the end 
of three years varying from 20 to 30. Some of these series of 
cases have been compiled from the operations of many different 
surgeons, and it is only fair to assume that the methods of 
operating and the selection of cases for complete operation 
have varied sufficiently to account for the differences in the 
ultimate result of operation. I still maintain that surgery 
should cure one-half of all cases provided that they can 
be subjected to the complete operation early in the course 
of the disease. 

In a series of twenty-one private cases, all that I had between 
the years 1898 and 1904, and every one of which has been 
followed accurately up to July i, 1907, fourteen patients, or 
66f percent, remain free from, any sign of recurrence whatso- 
ever, either regional or internal. That I am prepared to expect 
recurrences in some of these goes without saying. Realizing 
fully, however, the extent of the operation done in each case, 
I shall be much surprised if more than one or two develop 
trouble. Since 1904 I have operated on a much larger number 
of patients who have gone a year, a year and a half, two years, 
and two years and a half, without recurrence, but of course 
they cannot be included in the series. I may state here, how- 
ever, that I have never encountered among my own patients 
any case recurring after two years and seven months. 

I have made no effort to include any of my hospital cases, 
as it is impossible to follow them in all instances and is 
manifestly unfair to include a portion of them known to have 
been favorable. 

Naturally those cases in which the axillary glands are grossly 



Carcinoma. 255 

diseased, in which the tumor is firmly adherent to the skin, 
and in which ulceration has occurred, offer a less favorable 
prognosis than those in which these phenomena are not present. 
Those in which ulceration has taken place are the most unfavor- 
able of all. Of thirty-one patients operated upon after ulcera- 
tion had taken place Wunderli reports only two living at the 
end of three years. Cases in which the supraclavicular glands 
are involved also offer a poor prognosis, but I do not consider 
them inoperable unless the glands in the higher triangles of the 
neck are affected. Although I cannot state that I have ever 
cured a patient, who had neck involvement, I had one who went 
four years without recurrence above the clavicle even though 
recurrence took place in the breast incision within three years. 
I therefore believe that life may be prolonged and rendered 
tolerable by operating upon patients who have involvement 
of the lower cervical glands. 

A question of importance relative to the prognosis in cases 
which have been subjected to operation is, ^'when may a pa- 
tient be considered to have passed the danger of recur- 
rence?" While all recognize that Volkmann's three-year 
limit is too short and should be extended to at least five 
years, it is nevertheless a fair working rule, inasmuch as 80 
or 85 percent of all patients who pass this limit remain free 
from subsequent trouble. After five years probably less than 
10 percent of all cases show recurrence. Of twenty recur- 
rences analyzed by Marggraff twelve took place during the 
third and fourth years and four during the fifth and sixth 
years. These figures are very significant. A five year limit 
is of course far from being absolutely protective, but a limit 
which is so cannot be set, inasmuch as recurrences have been 
known to take place after ten, fifteen, twenty and even twenty- 
five years. 

The subject of late recurrence has recently been investigated 
by Ransohoff, of Cincinnati. He collected thirty-seven cases 



256 Diseases of the Breast. 

in which recurrence took place after seven or more years. Of 
these twenty-six were clearly local, and eleven were doubtful. 
Warren, Carson, Bevan and Senn have each had a case after 
eight years. Shepherd has had one after nine and eleven 
years respectively; Moore and Vanderveer each one after 
twelve years; McLaren one after thirteen years; Armstrong 
and Bloodgood each one after fifteen years; Coley one after 
seventeen years; Ransohoff one after twenty years; Deaver 
one after twenty years; Matas one after twenty-five years. 
RansohofT states that he was unable to find any case in literature 
in which the interval between the time of operation and the 
recurrence of the disease was as long as twenty years. The 
cases of Deaver and Matas were reported to him in personal 
communications. (See RansohofT's paper in Transactions of 
the American Surgical Association, iQo?-) 

My belief is that nearly all such reported late recurrences 
are really not recurrences at all, but fresh outbreaks in subjects 
with a demonstrated susceptibility to the disease. This I 
believe to be particularly true in regard to recurrence in the vis- 
cera and bones. It is difficult to understand how cancer-cells 
could lie dormant in internal organs for so many years without 
giving trouble. Certainly internal cancer affecting such organs 
as the stomach and rectum, for instance, where there is no 
direct lymphatic connection with the mammary gland, can 
be better understood and explained on the theory of a fresh 
outbreak than by supposing them to be directly the result of a 
carcinoma of the breast antedating them by a decade or longer. 

Do we believe that cancer of the liver, stomach, uterus and 
other internal organs runs such a quiescent course that patients 
live without symptoms for many years ? By no means ! And 
yet we must suppose that such is the case if they are secondary 
growths following a primary focus in the breast which was re- 
moved years before, and which itself has shown no signs of re- 



Carcinoma. 257 

If local recurrence takes place, then it is presumable that 
cancer-cells were left behind at the time of operation. But 
even in such cases is it not conceivable that we may have 
malignant degeneration in a cicatrix, which we know is prone 
to occur in other parts of the body in non-carcinomatous pa- 
tients ? Much more likely is it to occur in those with known 
predisposition to the disease. 

Of all the factors influencing prognosis the variety of the 
neoplasm is the most important. Medullary carcinoma is 
the most malignant, adenocarcinoma the least. Scirrhus occu- 
pies an intermediate position, and, as already stated, withering 
or atrophic scirrhus is less virulent than the ordinary form. 
The rapidly fatal course of acute cancer has also been alluded 
to, and the hopelessness of cancer en cuirasse set forth. 

As regards age, I believe that mammary carcinoma pursues 
a more fatal course in young persons than in old, for the reason 
that in the former class the lymphatics are both more numer- 
ous and more patent. 

Concerning operative mortality, my statistics collected three 
years ago are significant. These statistics, based on 2133 
operations, performed between the years 1893 and 1903, by 
twenty-one American surgeons, show the death rate to be 
less than one percent. This seems almost incredible when 
contrasted with the fifteen to twenty-five percent mortality 
following incomplete operations in pre- antiseptic days. 

[Since the above went to the printer, Halsted's most recent 
article* has appeared. It particularly emphasizes the desira- 
bility of operating before axillary or other lymphatic involve- 
ment. Of 64 such cases operated, 80 percent were free from 
recurrence and apparently well at the end of three years. It 
is true that many of these cases were adenocarcinomata, in 
which there is little tendency to lymphatic involvement. 
Therefore, early operation should be insisted upon, for if 

*Annals of Surgery, July, 1907. 
17 



258 Diseases of the Breast. 

done before axillary involvement, four out of five may be 
cured. 

Halsted's statistics also show that where there was involve- 
ment of the axillary glands, there were only 24.5 percent of 
cures; so with axillary involvement the chances of cure are 
about one in four, without axillary involvement, four in five. 
No stronger argument could be made for prompt interference 
in any suspicious growth of the breast. 

It also appears from this publication that in at least two. 
instances Halsted encountered decided axillary involvement 
when the primary focus in the breast was so obscure as to 
escape notice. 

Halsted still insists upon the neck operation, doing it in 119 
cases of the 2^2 reported. In 44 patients the glands of the 
neck as well as those of the axilla were involved. ''Three of 
these (or 7 percent) were, it seems, definitely cured." 

It will, therefore, be seen that the statistics of the Johns 
Hopkins Hospital (232 cases covering a period of more than 
15 years) indicate that 27 percent of the patients at the time of 
operation were free from axillary involvement. Halsted himself 
evidently thinks that this showing is too favorable, as he says 
very properly: " We must bear in mind, however, that surely 
in some and probably in many, if not in most of the axillae 
recorded as negative, there was disease." 

In my own series of 21 private patients where this feature 
was carefully noted and recorded, but two of them, one of 
adenocarcinoma and one of scirrhus, showed negative axiUse 
at the time of operation. It is my invariable custom to submit 
all axillary tissues removed to the microscopist and never to 
wholly depend upon macroscopic appearances. 

It is evident, that my cases were at least of average, if not 
more than average, severity. One of them had been operated 
upon twice before by other surgeons for an infiltrating scirrhus; 
at the time I operated there was little hope for a radical cure, 



Carcinoma. 259 

although I did a very extensive operation and almost lost the 
patient from shock. She has now been well ten years.] 

Treatment. — There is but one treatment for cancer of the 
breast — operation — and the earlier and more radical it is, 
the better. It should be a work of supererogation, at this 
time to insist upon the fact that operation, and it only, is of the 
least avail in this frequent and distressing malady. In dealing 
with cancer pessimism is so easy, optimism so difficult, that we 
can hardly expect any but the younger medical men to diagnos- 
ticate and refer their cases for early operation. The false 
teaching of a past era still abides with many of the older practi- 
tioners, and they can neither make an early diagnosis nor ap- 
preciate the necessity of sending their cases to some one who can. 

The internist should definitely refuse to treat neoplasms of 
the mammary gland, for all of them are strictly surgical; they 
are generally malignant, and, therefore, amenable only to 
operative procedures. 

He has learned, or is fast learning, his lesson in appendicitis, 
strangulated hernia, and other such acute affections having 
a rapid and tragic end without surgical intervention; but in 
gall stones we still hear much of olive oil and in gastric ulcer too 
much about diet and drugs, which, valuable as they are, 
frequently are persisted in until either hemorrhage or perfora- 
tion rings in the last scene to the drama. But in cancer of the 
breast, stomach, and other organs where there is absolutely 
no excuse for delay, and where the course of the disease is 
relentless and certain, the same responsibility is not felt on 
account of the chronic nature of the disease. It is, however, 
undoubtedly a far greater responsibihty, for in acute disease 
nature may bring amelioration, if not relief; whereas in cancer 
the neglect of the family physician, who first sees the case, may 
condemn his patient to the tnost painful, lingering, and loath- 
some of deaths. 

The law holds a practitioner responsible for failure to report 



26o Diseases of the Breast. 

certain infectious diseases, as the welfare of the pubhc requires 
correct and prompt action on the part of medical men. That 
we are nearing the time when probably the law, but certainly 
public sentiment, will hold one responsible for a failure to 
give the proper advice to patients with cancer, there can be 
little doubt. It is, in my judgment, no longer justifiable to 
deceive patients as to the nature of their disease, for, by so 
doing, they are lulled into a false security and prevented from 
doing that which they are nearly always willing to do when the 
matter is properly and intelligently put before them. Rarely 
have I had a woman dechne interference for cancer of the 
breast when the risk of the operation and the hazards of delay 
were fairly and relatively set forth. As long as cancer was 
synonymous with death, a want of candor was pardonable, 
perhaps humane; but now that early operation rightly done 
will cure at least one- third, probably one-half, of mammary 
carcinomata, patients and their friends should be plainly told 
the truth, delicately and with consideration, of course, but 
the truth nevertheless. 

The public understands fairly well the possibilities of surgery 
in certain diseases and it is not to be questioned that it will 
look for and discover those who have, and whose results give 
them a right to have, a reasonable amount of optimism in the 
surgery of malignant disease. 

I count myself fortunate, along with many others, to have 
had the privilege of listening to the teachings and to have 
followed as house surgeon in the wards and operating room of 
Jefferson Hospital, that brainy, aggressive, and prescient sur- 
geon, Samuel W. Gross, who was curing a definite, though a 
small percentage of mammary carcinomata at a time when 
others looked upon operation as little short of leading a forlorn 
hope, and spoke of this Apostle of a new faith as a misguided 
optimist. An equally illustrious surgeon and teacher in this 
city was, at the same time, declaring that he had removed a 



Carcinoma. 261 

'^cart load of breasts for cancer and had not obtained'a single 
cure." The teaching of these two men is felt in Philadelphia 
to-day, and is in a measure exemplified in the practice of their 
respective pupils, though a generation has passed. The one 
greatly advanced the cause of surgery of the breast, the other 
as much retarded it. 

Latterly it has become somewhat the custom with practi- 
tioners to recommend a course of X-ray treatment before 
operation. The practice cannot be too pointedly condemned 
inasmuch as it has been productive of little, if any, good even 
in a minority of cases, and in all wastes valuable time — possibly 
allowing internal metastases to occur before operation is 
instituted. I regard the practice of using X-rays, or other 
local treatment before operation, as always injudicious, often 
positively injurious and, therefore, highly censurable. I 
shall later speak of this remedy as supplementary to operation 
and in the treatment of inoperable growths. 

Before any operation in mammary cancer, we should always, 
so far as possible, eliminate the probability of internal metas- 
tasis. The liver, the lungs, and bones should be carefully 
interrogated, as these organs are most often the sites of secon- 
dary foci. That it will be clearly impossible to recognize 
beginning infection in any of these is, unfortunately, true; 
but gross or palpable invasion should prevent an operation 
for the removal of the primary focus unless it be undertaken 
simply as a palliative procedure and with no hope of a radical 
cure. Such operations do but little good and discredit both 
the operator and surgery. 

One has only to follow the operation for cancer of the breast 
through its various evolutionary stages, to be convinced that 
the radical procedure, as we now understand it, is as much 
better than the partial operations practised before Halsted's 
epoch-making paper in the Annals of Surgery in 1894, as these 
were better than the caustics, electricity and internal medica 



262 Diseases of the Breast. 

tion of former days. The argument often made that extensive 
operations are not justifiable in cases seen early is entirely 
erroneous. Truth to say, early cases are the very ones where a 
complete operation should be done, as there is for them a sub- 
stantial hope of a permanent cure. Moreover, it is impossible 
to determine by any examination, however carefully conducted^ 
the exact limits of a growth that is always unencapsuled and 
infiltrating in its nature, such as cancer. Therefore, it is 
always safe to assume that there is a more extensive zone of 
infection than is apparent, and that it is wise to remove enough 
tissue to insure its probable complete eradication, inasmuch 
as this can be done without increasing the operative mortality 
or lessening the future usefulness of the patient. To do this 
one must constantly keep in mind the fact that carcinoma 
generalizes through the lymphatics, and that early, very early, 
in the disease the axillary lymphatic glands become involved, 
so that in any operative procedure the primary focus in the 
breast, the axillary nodes, and the intervening lymph-bearing 
vessels containing cancer cells must be simultaneously removed. 
Hence the utter inadequacy of treatment by caustics, which 
at the most can only reach the primary focus in the breast, and 
can only do this in small, discrete growths at the expense of 
great pain, sloughing, and probable sepsis. 

Caustics. — The treatment of cancer of the breast by 
various pastes or caustics has no place in surgery and should 
not for a moment be countenanced. Valuable as they are 
in certain squamous epitheliomata of the face, where there is 
little tendency to glandular infection and where it is desirable 
to avoid disfigurement, they are wholly inadequate to cope 
with acinous carcinoma in an organ like the breast. I feel 
like offering an apology for dignifying them by mention and 
only do so because they, along with the Roentgen rays, are 
still given an amount of credit altogether out of proportion to 
their deserts. 



Carcinoma. 263 

The trypsin, or trypsin-amylopsin, treatment of carcinoma, 
based upon Beard's theory that wandering embryonal cells 
develop into malignant neoplasms owing to the fact that they 
have escaped the destructive action of certain enzymes, is 
mentioned here for the purpose of condemning it as a curative 
measure. The practitioner should guard himself well against 
the acceptance of such extravagant assertions as have been 
made by a few enthusiasts in favor of this treatment. 

This is not the place to discuss Beard's theory of the causa- 
tion of cancer. It will suffice to say that his ideas have not 
been accepted in their entirety by those best qualified to judge 
of the matter. 

Concerning the trypsin treatment itself, a complete analysis 
of the clinical evidence obtainable, such as has been recently 
made by several investigators, notably Dr. Ellen C. Potter, 
of Philadelphia, shows that no specific action is exerted by the 
ferments. Dr. Potter very appropriately calls attention to the 
circumstance that changes in malignant growths similar to 
those supposed to have been produced by trypsin have occurred 
in tumors which were not subjected to any treatment what- 
soever, and have also been observed in those treated with 
bacterial vaccines. 

As a palliative measure in inoperable cases, and in those 
in which operation is refused, the treatment may be employed. 
It is stated that ulceration has been limited or arrested, that 
gain in weight has taken place, and that improvement in the 
general condition has occurred under its use. These con- 
siderations, if true, are important. At all events they are 
encouraging, as they offer a possibility of adding somewhat 
to our measures of relief for inoperable cases. 

To employ such a novel and fanciful method of therapy in 
lieu of operation would be highly injudicious, indeed censurable. 

Oophorectomy, which was first recommended by Air. Beatson, 
has occasionahy been performed as a therapeutic measure 



264 Diseases of the Breast. 

in inoperable mammary cancer. As I have had no experience 
with it, I cannot do better than quote Mr. Hugh Lett, who 
has made an exhaustive study of the subject, based upon 
ninety-nine cases. 

His conclusions are as follows: 

(i) There was a very marked improvement in 23.2 per- 
cent, and distinct, though less marked, improvement in 13 
other cases; that is, 36.4 percent of all cases operated upon 
were materially benefited by the operation. If the patients 
who were more than 50 years old are omitted, of the remaining 
75 cases 29.3 percent showed very marked improvement, 
and nine others showed distinct improvement; that is 41.3 
percent were benefited by the operation. 

(2) In successful cases the benefit has been great, and is 
mainly shown in relief from pain, marked improvement in 
health, diminution or even disappearance of the growth, 
healing of ulcers, and prolongation of life. 

(3) The duration of the improvement is not very often stated, 
but in 15 cases the improved condition was maintained for 
more than twelve months and four other patients had good 
health for 4J years or more. 

(4) Oophorectomy does not cure the disease, for in all the 
cases in which the growth has disappeared after the operation 
it has subsequently reappeared, locally or elsewhere, with the 
exception of one patient, whojs ahve and free from recogniz- 
able cancer at the present time, five years after oophorectomy. 

(5) The most favorable age for operation is from 45 to 50; 
in relatively young patients it should be given a further trial, 
but after 50 it is rarely worth doing. The fact that the patient 
has passed the menopause does not contraindicate the operation. 

(6) Thyroid extract is not a necessary factor in the treat- 
ment, although the results have been slightly better when it 
has been given. 

(7) Secondary growths in the viscera contraindicate the 



Carcinoma. 265 

operation; rapidity of growth, or an early recurrence after 
the primary operation, makes the prognosis unfavorable. 

(8) The mortahty in this series of cases is high — a little over 
6 percent. It should be noted, however, that the actual 
cause of death in several of these cases may be regarded as 
accidental ; in two the fatal issue was due to pulmonary embo- 
lism and in one to acute mania. 

Since the somewhat tardy acceptance and adoption of radical 
operative measures by surgeons in general, the number of cures 
has not only doubled, but quadrupled. While it is true that 
occasional permanent cures were recorded before Moore's paper 
in 1867, they were accidental and fortuitous and must have 
been in favorable cases with only a primary focus in the breast, 
and without extensive cutaneous, muscular, or axillary involve- 
ment. Further, it is not unhkely that many of the cases sup- 
posed to have been cured were non-cancerous, as the custom 
before Moore's paper was not so general as it is now of sub- 
mitting all tumors, after their removal, to the microscope. 
Still, a careful study of the work and teachings of Astley Cooper 
and Velpeau indicates strikingly their familiarity with the 
anatomy of the breast and its outlying rudiments, the gross 
pathology of the disease, and their appreciation of the necessity 
for a free excision for its complete eradication. That their 
work in mammary cancer stands out in bold relief from that 
of their contemporaries is nothing more than should be expected 
of two such masterful minds, making as lasting an impression 
upon the surgery of their respective countries, and the world, 
as it is given to men to do. 

Sir Astley, who is still quoted by the anatomists for his 
original work on the Anatomy of the Mamma, shows in his 
writings an accurate knowledge of the pathology of cancer: 
"The scirrhus tumor is not all of the disease; there are roots 
which extend to a considerable distance. When you dissect 
a scirrhus tumor you see a number of roots proceeding to a 



266 Diseases of the Breast. 

considerable distance; and if you remove the tumor only, and 
not the roots, there will be little advantage from the operation.'^ 

The great clinician, Velpeau, spoke positively and authori- 
tatively in the early fifties, reporting a score of cases which 
had not only passed the three year limit, which is required 
to-day, but had all even passed a five year limit; some of the 
patients had lived without recurrence for twenty-five years after 
the operation. It is refreshing to read such words as these 
from this surgical master written more than half a century ago. 
"Des Observations tirees de ma proper pratique demontrent, 
sans contestation possible, 1' existence de guerisons radicales 
par I'operation." These words are in strange contrast with the 
teachings of the elder Gross, Paget, and Virchow, his con- 
temporaries in America, England and Germany, and other 
leading surgical pathologists of their time. 

As long as the constitutional origin of cancer was adhered 
to, nothing but pessimism could permeate those who con- 
templated its removal by local means. 

History of the Operation for the Cure of Mammary Car- 
cinoma. — The author of the modern, or complete operation,, 
as we understand it to-day, is unquestionably Mr. Charles 
Moore, formerly a surgeon of the Middlesex Hospital, London,, 
who, in 1867, pubhshed a paper, remarkable for its foresight 
and keen observation, ''On the Influence of Inadequate Oper- 
ations on the Theory of Cancer."* 

That others, Velpeau for instance, had suspected much that 
was true cannot be doubted, but it remained for Moore to 
enunciate clearly and distinctly principles which are to-day 
accepted everywhere. In fact his views were so much at 
variance with the prevailing English opinion of their time,, 
that his teaching became an "accepted tradition only at the 
Middlesex Hospital," f being rejected elsewhere in England 

* Trans. Royal Med. Chir. Soc, Vol. I, 1867. 
t Handley's Carcinoma of the Breast. 



Carcinoma. 267 

until it was strenuously advocated in 1882, fifteen years later ^ 
by Sir Mitchell Banks, of Liverpool. Meantime, however, the 
Germans, Danes, and Austrians had been actively at work in 
putting into practice the teachings of Moore, and are undoubt- 
edly entitled to the credit of popularizing the complete opera- 
tion. In this work Volkmann was foremost. 

S. W. Gross, in America, was quick to appreciate the ex- 
cellent work of German surgeons, and in the late seventies 
began to teach and practice the principles laid down by Moore. 
I personally assisted him in such operations during my service 
as interne in the Jefferson Hospital during 1879-80. 

Moore's teaching, while often referred to, is not as thoroughly 
understood even by surgeons and teachers as it should be, for 
it was he who shattered and utterly demolished the constitu- 
tional theory of cancer, which had been accepted by the pro- 
fession, and had made operative advance wellnigh impossible. 
He insisted that the entire breast should be removed and with 
it all involved structures such as skin, fat, pectoral fascia, 
pectoral muscle, and enlarged lymphatic glands. Moreover, 
he emphasized that it should be done in such a way that the 
growth was neither cut into nor seen, which means that the 
diseased structures should be removed en masse — a detail 
much insisted upon of late without giving credit to Moore. 

Volkmann was probably the first to remove the pectoral 
muscles— major in a series of 38 cases, minor in a much 
smaller number. His results in this series, though the cases 
were more advanced, with cancerous infiltration of one or both 
muscles, were much better as far as regional and local recur- 
rences are concerned, than in his milder and altogether more 
favorable cases where the muscles were not removed because 
apparently healthy. 

Heidenhain recommended that the fascia covering the 
pectoralis major, along with the most superficial fibers of the 
muscle itself, be removed. He believed this to be enough, as 



268 Diseases of the Breast. 

he demonstrated that the lymph current was from and not in 
the direction of the fascia. It should not be forgotten, how- 
ever, that S. W. Gross advised and practised removing the 
pectoral fascia in 1879, and that Volkmann had done so in 
1875. Thus Heidenhain only emphasized the previous teach- 
ings of Moore (1867), Volkmann (1875), and Gross (1879), 
supplementing them with careful microscopical studies and a 
better understanding of the lymph currents. More credit 
than the facts warrant has been given to him by English and 
American surgeons. 

To Halsted, however, is due the credit of advising the 
removal of the muscles in every case regardless of infection. 
I quote from his paper of 1894: "The pectorahs major 
muscle, entire or all except its clavicular portion, should be 
excised in every case of cancer of the breast, because the oper- 
ator is enabled to remove in one piece all of the suspected 
tissues. The suspected tissues should be removed in one piece, 
(i) lest the wound become infected by the division of tissues 
invaded by the disease, or of lymphatic vessels containing cancer 
cells, and (2) because shreds or pieces of cancerous tissue 
might readily be overlooked in a piecemeal extirpation." 

Willy Meyer* about the same time advised the removal of 
the great pectoral and urged in addition that the lesser pectoral 
be also removed so as to insure a more complete axillary dis- 
section. 

Recent investigations by Grossmann and Rotter indicate 
clearly the wisdom of removing the muscles always, as the 
major muscle is involved in fifty percent of all cases, and it 
is simply impossible to remove infected tissue — lymphatic 
vessels and glands between them — without doing so. Further, 
Rotter insists that in one-half of all cases there will certainly 
be found enlarged lymphatic glands between the muscles 
which cannot be recognized with the pectorals in situ. Gross- 

* Medical Record, 1894. 



Carcinoma. 269 

mann succeeded three times in thirty subjects in injecting a 
lymph- bearing vessel from the mammary gland, which per- 
forated the great pectoral, running between it and the pectoralis 
minor, to empty finally into the subclavian or topmost axillary 
glands. It is along the course of this vessel that Rotter found 
enlarged glands. 

I have during the past year operated upon two cases with 
well marked retro-pectoral enlarged nodes, calling the atten- 
tion of my assistants to them, and to the observations of Rotter. 
I am convinced that the nodes would have been overlooked 
in both cases had not the great pectoral been removed. The 
experiments of Grossmann and Rotter demonstrate the wisdom 
of Halsted's and Meyer's suggestion, that the muscles be 
removed in every case regardless of infection. The great 
pectoral is so frequently diseased as to be a menace if left 
behind; the small pectoral, while less frequently infected, is a 
barrier to one, if not the most essential step, of the operation, 
namely, a thorough axillary dissection. I hold that it is 
exceedingly difficult, if not impossible, satisfactorily to clear 
the space of Mohrenheim — between the upper border of the 
tendon of the pectoralis minor and the clavicle — of fat, glands, 
and the fascia covering the vessels without injury to the latter 
if the muscles are in situ. The retention of the muscles is of 
no special value, so far as the future usefulness of the arm is 
concerned, and their removal or division is a necessity for 
thorough and accurate work. 

I know there are some who conscientiously think that they 
do a perfect axillary dissection by the skilful use of retractors — 
without division or removal of the muscles. I was thus 
deceived for several years, but now fully realize that my work 
was incomplete, and, moreover, understand recurrences which 
were at the time both disappointing and disheartening. 

There are from three to twelve lymphatic glands in Mohren- 
heim's space, and when infected these nodes receive afferent 



270 Diseases of the Breast. 

vessels from all of the axillary glands below. These glands 
are intimately associated with the axillary vein, lying to its 
inner aspect at the point where it receives the cephalic vein. 
When these glands are enlarged or adherent to the vessels, 
injury is easily done to the axillary or cephalic vein, unless 
their removal is accomplished by careful dissection. To leave 
them behind would doom inevitably any operation to failure. 

Another reason for removing the lesser muscle is the occa- 
sional presence of enlarged glands between the vein and the 
artery, which can only be reached by lifting up the vein and 
displacing it inwards. This can easily and safely be done by 
means of a small retractor, provided the muscles have been 
removed or divided and then retracted. 

Removal of the fascia surrounding the vessels is also desir- 
able, and presupposes the removal of the muscles. This 
step certainly requires that the vessels be not only exposed, 
but seen in a good light. 

I have, I trust, given satisfactory reasons for believing that 
the muscles should preferably be removed in every case, and 
have sho^^m how recent anatomic investigations and exper- 
iments demonstrate forcibly the correctness of the teaching and 
chnical judgment of Halsted as expressed in 1894. 

That the removal of the muscles is necessary in every 
•case no one will or should maintain, as nearly all doing work 
in this line have indubitable cures to their credit where the 
muscles were spared, the patients having long since passed the 
period of probable danger. These, however, were early and 
favorable cases, and the removal of the muscles has simply 
become a natural, logical, I may say, inevitable step in the 
•evolution of the operation. 

Supraclavicular Glands. — In 1892 Halsted first practised 
removal of the supraclavicular glands, and in his paper of 
1894 advised that it be done as a routine procedure. Prior to 
this time it had never been done and, moreover, enlarged 



Carcinoma. 271 

cervical glands were unanimously considered an absolute 
bar to operation. In short, such a case was thought hopeless. 
Halsted's suggestion has not been generally adopted by Amer- 
ican surgeons, and few outside of Johns Hopkins Hospital 
have removed the glands of the neck unless palpably enlarged 
or unless there was macroscopical involvement of the topmost 
axillary glands. Twenty-five American surgeons to whom 
I addressed the question, "Do you explore the supraclavicular 
space?" answered that they did not unless there was palpable 
involvement. Two believe that it should be done more often, 
on account of recent anatomical discoveries. In this opinion 
I distinctly concur, and have made it an invariable rule to 
explore the subclavian triangle if the tumor is a peripheral 
one in the upper hemisphere, since the discovery by Poirier 
and Cuneo of a set of lymphatic vessels which drain the upper 
half of the breast, thence passing over the clavicle to empty 
into the supraclavicular lymphatic glands. As carcinomata 
are so often located in the upper and outer quadrant of the 
breast, I should say that it would be safer to explore the neck 
in a majority of instances, and I have done so for the last four 
years. I have but infrequently found it involved; still I do 
not feel that my duty has been accomplished until the incision — 
the work of a moment — is made. 

Halsted and his associates at the Johns Hopkins Hospital are 
removing the glands of the neck in a decreasing number of 
cases, and it is equally true, I think, that other American sur- 
geons are operating upon the neck in an increasing number ; so 
that Halsted's original position, while possibly extreme, has been 
productive of good and brought the rest of us up to the mark. 
I do not question the wisdom of the procedure if there is notice- 
able enlargement of the supraclavicular glands, if the sub- 
clavian chain of the axillary glands are at all enlarged, or with- 
out such enlargement in all cancers of the upper hemisphere. 

Therefore, recent discoveries entirely support Halsted in 



272 Diseases of the Breast. 

his contention that the neck should be often explored. To 
give his exact position I quote from a letter from him: "Of 
76 cases cured three or more years, the supraclavicular glands 
were involved (and of course removed) in 7 (9 percent). 
The involvement of the supraclavicular glands is, of course, 
much greater than 9 percent, where all cases in which the 
complete operation has been performed are included. The 
proof, then, is definite and ample that the supraclavicular 
operation is indicated in many, perhaps most, cases of carci- 
noma of the breast." 

I cannot say that I have cured a patient with neck involve- 
ment, yet one lived for four years after operation without 
regional recurrence in the neck, but had lethal recurrences in 
the breast incision. Though this patient was not cured, her 
case at least taught me that very decided enlargement of 
cervical glands low down — they altogether made a mass as 
large as a small lemon — does not necessarily mean inoper- 
ability. If glands in the higher triangles are involved, the 
case is clearly inoperable. 

Skin Incision. — The early, frequent, and extensive involve- 
ment of the skin in mammary cancer demanded, and should 
have received, in the incipiency of its operative treatment, a free 
removal of the integument covering the affected breast. This 
is particularly so as the principal lymph channels draining the 
breast are known to be in the skin; Sappey and other early 
anatomists beheved that nearly all such vessels were to be 
found there. Yet in spite of anatomy, pathology and successful 
surgery calling for a free removal of skin as the prime con- 
sideration — even of greater moment possibly than a complete 
extirpation of the gland and its outlying rudiments — we still 
often see practised the antiquated eUiptical incision of our 
forefathers. So little of the infected integument is removed 
by these incisions that subsequent steps in the operation, 
however well planned and carried out, are necessarily futile. 



Carcinoma. 273 

I wish to state positively my belief that the excellent results 
of Gross and Banks must have been due to the free removal 
of skin practised by each, for neither of them sacrificed the 
muscles — the former dying in 1889, five years before Halsted 
suggested it as a routine procedure and the latter, though living 
until 1904, never believed removal of the muscles necessary. 

I was the guest of Sir Mitchell in 1904, saw him brilliantly 
do his last two operations for mammary cancer, and afterwards 
discussed freely with him the value of removing the muscles. 
He could not be convinced that he had for so many years 
omitted an important step in an operation which he did so 
much to perfect and with which his honored name must forever 
be associated. In a letter written me a few days before his death 
he reviewed his work, spoke hopefully of the operative treat- 
ment of cancer, and especially insisted upon a large ring incision. 
His operations reminded me of Gross's '^dinner plate incision." 

To give some conception of the magnitude of Gross's oper- 
ation, I may relate that I was assisting him one day when he 
remarked to a friendly guest present, "I will show you my 
dinner plate incision." It was an enormous breast, the wound 
made unusually large, and when he had finished, the astonished 
onlooker said ^'dinner plate, h — 1, it looks more like a cart- 
wheel." We all had a good laugh over the remark, and I shall 
never forget the surprise of his friend and the gratification of 
Gross, for he was immensely pleased that the size of his incision 
had been emphasized even with language more forcible than 
elegant. 

Gross cured 21.5 percent of his cases; Banks 21 percent, 
and, as neither did what is to-day regarded as a good axillary 
dissection, because neither removed the muscles, their results 
must have been largely due to their wide removal of skin. 
Banks usually succeeded in closing his wound, or the greater 
portion of it, by extensive undermining of the skin. Gross 

allowed his wounds to heal by granulation. I have never seen 

18 



274 Diseases of the Breast. 

two surgeons operate so similarly as did Banks and Gross in 
their breast work, and it is shown in their results, 21 and 21.5 
percent of cures respectively. 

Halsted makes a large wound — almost as large as that of 
either of the above mentioned surgeons — and supplements 
it by skin grafting — a distinct improvement and advance. 
The more I graft the better am I satisfied with my work, for 
there is no fear of probable failure to secure primary union — a 
fear which I believe always more or less fetters one when 
making any of the flap or plastic operations. That the best 
of them may often succeed admirably in meeting all require- 
ments, pathological and surgical, there is no question; but that 
they sometimes fail, on account of infected skin being retained, 
is certain. 

In large tumors with extensively adherent skin, the ring or 
dinner plate incision supplemented by skin grafting, preferably 
at the same operation, will be safer. 

The disposition of some to graft later when the wound has 
begun to granulate has little to recommend it, as it necessitates 
a second anesthesia and is not so likely to succeed as when done 
primarily. That there is somewhat of a prejudice against 
grafting both on the part of patients and profession is quite 
true. The scar it leaves is certainly unsightly; but it is supple 
and not inclined to contract and bind the arm as nearly all of 
the plastic procedures do. I distinctly favor it and am resorting 
to it in an increasing number of cases. 

The next decided step in advance was the removal of the 
fascia covering the pectoralis major muscle. As already 
stated the credit for this is generally ascribed to Heidenhain, 
who undoubtedly did much to popularize the procedure, and 
made experiments showing that the lymph current was from and 
not in the direction of the fascia. In removing the fascia he 
also shaved off the superficial fibers of the pectoralis major. 
While giving full credit for his work, I have shown that others 



Carcinoma. 275 

preceded him in this step of the completed operation. More- 
over, that he overestimated the value of removing the fascia 
cannot now be questioned [in view of more recent demon- 
strations, to which reference has already been made. 
In all tumors adherent to the costal wall and in those cases 
with retro-pectoral enlarged nodes it would necessarily be 
futile. 

Axilla. — When, why, and by whom the axilla was first 
explored in operations for mammary cancer, it would be 
difficult to say. Moore recommended the removal of axillary 
glands which were palpably enlarged (1867), and, according 
to Professor Cheyne, ''Lord Lister in the late sixties began 
doing a very free operation, which included in most cases the 
free removal of skin and ablation of the pectoral fascia and 
axillary glands."* But as the glands are palpably enlarged in 
''most cases" we may assume that Lister, at this early date, 
only invaded the axilla when it seemed to be necessary. That 
others did likewise, there is abundant testimony, for Volkmann 
in 1875 ^^^ Kiister before him believed it a necessary step. 
It remained, however, for the younger Gross in 1880, in his 
"Tumors of the Mammary Gland," to insist that the axilla 
be explored in every case, and to him belongs the credit of 
popularizing this step. I quote his words : " Even if I should 
be deemed too bold in recommending that the axilla be attacked, 
when it is apparently free from disease, surgeons of extended 
experience will certainly agree with me in regarding the adipose 
tissue as being largely infiltrated by young cells, for it is just 
precisely in corpulent subjects that local reproduction is most 
marked along the line of the cicatrix of partial operations, or, 
in other words, in the fat which they have been too anxious 
to save in order that they might secure thick and seemly flaps." 
Again in 1888, in his last publication, Gross insisted strongly 
upon the necessity of cleaning out the axilla in every case, 

*Handley's Cancer of the Breast, p. 172. 



276 Diseases of the Breast. 

calling attention to outlying lobules of breast tissue which must 
not be overlooked. I know that he did so during my student 
days in 1878 and my internship in Jefferson Hospital in 1879. 
He insisted upon what every one now believes, that enlarged 
glands in the axilla, especially in a fat subject, may elude the 
most careful examination before the axillary space is opened 
and explored. Therefore, he explored the axilla in every 
case of cancer. 

The fault with his work was that, far ahead of his time as it 
was, it did not go far enough, as he only reached the base of the 
axilla and depended upon a piecemeal extirpation. The 
axillary step of his operation would not be called thorough 
to-day, for I repeat, what has already been said, that a thorough 
axillary dissection cannot he made with the muscles in situ. 

The defect with the axillary dissections of Gross, and I 
believe with those of all others up to the time of Halsted, lay 
in the fact that a separate incision was made into the axilla, 
after the breast had been removed and lymph-bearing vessels 
had been cut across. Further, it was a small wound, per- 
mitting only a piecemeal removal of palpably enlarged glands, 
good thorough work under the guidance of the eye being im- 
possible. It was a long step in advance, but it fell far short 
of the mark. 

It is now interesting to see how all surgeons, American, 
English, German, and French feared invasion of the axilla 
on account of the increased risk. The mortality from the 
simple operation was fifteen percent, and double that when 
the axilla was attacked. For this reason some of the very 
best Enghsh authorities, Butlin, Treves, and others, seriously 
argued against the complete operation. Gross admitted the 
increased danger, but advised that it be assumed on account 
of the fruitlessness of the operation without it. 

How aseptic surgery has changed things and made really 
serious and able disquisitions of one time — and that not so 



Carcinoma. 277 

very long ago — seem trivial to-day! Truly has the prediction 
of Billroth come to pass: '^I should not be surprised if an 
experienced operator were to succeed in doing 100 consecutive 
extirpations with but a single death." He admitted a death 
rate of more than 20 percent, counting all of his cases, and 
got his best results from the complete operation under strict 
antisepsis (1877-79), his mortahty then dropping to 5.8 per- 
cent. The operative mortahty in 2133 operations performed 
since 1893 by twenty-one American surgeons reporting to me 
was less than one percent. 

In 231 operations performed under strict antiseptic pre- 
cautions by Lister, Volkmann and Billroth, the mortality was 
6 percent.* True, these operations were done in the decade 
from 1 8 70-1 880, but all were in the hands of the best exponents 
of antiseptic surgery. 

The best results, secured from any standpoint, have been 
gained since Halsted's paper in 1894, which may justly be said 
to mark the second epoch in surgery for mammary cancer. 
Twenty-seven years after Moore's publication, it re-affirmed 
and with greater emphasis, because it was supported by incon- 
trovertible statistics, every position taken by Moore, going 
many steps in advance of him and every one else. 

The axillary feature of Halsted's operation is its best; all 
glands, fat and fascia covering vessels and muscles are removed 
en masse, and nothing left from apex to base but vessels and 
nerves. A piecemeal extirpation is to be condemned. 

Removal of Deep Fascia. — In 1904, Mr. Handley, in a paper 
read before the Surgical Section of the British Medical Associa- 
tion, advised a still more extensive operative procedure than had 
hitherto been practised, founded upon his theory of permeation 
of cancer cells along the deep fascia. I was much impressed 
by hearing his paper and the discussion which followed it, 
and since then have myself practised a freer removal of the deep 

* Williams' Diseases of the Breast, p. 362. 



278 Diseases of the Breast. 

fascia than before. I beheve he is right in advocating that the 
fascia covering the upper part of the rectus and external obhque 
muscles be removed to a greater extent than heretofore. I 
always remove the fascia covering the serratus and subscap- 
ularis muscles. 

I am hardly prepared, however, to accept the suggestion 
given in his recent excellent treatise on cancer, that the digita- 
tions of the serratus magnus and external oblique muscles be 
removed. It seems to me that the limits of the operation have 
about been reached and that to carry it out conscientiously 
in every detail the complete operation, as we now understand 
it, will require from one to two hours, according to the rapidity 
of the work. Moreover, I am not convinced of the necessity 
for removing these muscles as a routine procedure. Car- 
cinomata are usually located in the upper and outer quadrant 
of the gland, a small part of which lies in contact with the 
serratus and does not touch the external oblique. It would, 
therefore, seem a work of supererogation to remove even a 
portion of these muscles unless adherence to the costal wall 
has taken place. In large growths of the lower and outer 
quadrant, especially if the gland is adherent to the costal 
wall, and, therefore, in contact with both muscles, the 
fascia covering them should certainly be removed and along 
with it the superficial fibers of the muscles themselves. I 
would not be disposed to remove the digitations in their 
entirety, as it would seem to me that any case so far advanced 
as to make this necessary is hopeless and beyond the reach of 
surgery. 

Removal of the Breast. — Since Stiles's* valuable contribution 
to the surgical anatomy of the breast, it is reasonably certain 
that in many, perhaps most, operations prior to that time the 
diseased mamm^ were incompletely removed. He showed by 

* Edinburgh Medical Journal, 1892. 



Carcinoma. 279 

careful investigation and his nitric acid test,* that the gland is 
a much more extensive structure than was formerly believed, 
and that the periphery and detached portions were necessarily 
left behind after any of the usual operative procedures of the 
time. His work was most valuable and contributed greatly 
to the '^complete operation" of the present day. He clearly 
demonstrated that the gland often extends up nearly to the 
clavicle, always considerably below the margin of the pectoralis 
major, overlapping the serratus magnus, external oblique and 
rectus muscles. Externally it is prolonged into the axilla, 
making a well-marked axillary tail. 

Stiles's paper was a positive demonstration that nearly all 
of the elliptical incisions formerly employed were inadequate 
for the removal of the breast in its entirety. His investigations 
strongly emphasized the necessity of either a very free removal 
of skin as practised by Banks and Gross in their circular 
incisions, or an elliptical incision which is supplemented by 
extensive undermining of the integument and free removal of 
para-mammary fat. 

Para-mammary Fat. — More has been said, perhaps, than is 
necessary about the removal of fat, para-mammary, axillary, 
and in the flaps. Yet it is of the greatest importance to remove 
the fat, because in doing so the very small lymphatic glands 
are at the same time removed and might be overlooked if the 
fat were left behind. The axillary fat, as has already been 
said, should go, every particle of it, along with the fascia. If 
the circular incision, the racquet incision of Warren, Jackson's 
method, and the best of the numerous elliptical incisions, to 
be described later on, be rightly done, httle uneasiness need be 
felt concerning the para-mammary fat. It will have been 
attended to in the planning of the preliminary incision. 

fWash the breast in running water to free it from blood, immerse it in a 5 
percent solution of nitric acid for ten minutes, wash again and then put it in 
methyl alcohol, The epithelial structures assume a dull, opaque grayish hue. 
which differs markedly in appearance from the stroma. (Edinburgh Medical 
Journal, June, 1892.) 



28o Diseases of the Breast. 

We have traced the several important steps of the operation 
for cancer of the breast through their various evolutionary 
changes until we now have the complete operation as it is 
understood and practised by the best surgeons the world over. 
Briefly to summarize, they are: A jree removal of skin; com- 
plete extirpation of the breast with the para-mammary fat; 
removal of the pectoral muscles ; a. complete dissection of the 
axilla; and a sufficiently free removal of deep fascia covering 
the rectus, serratus magnus, and external oblique. All tissues 
must be removed in one piece and without undue or forcible 
manipulation^ so as to avoid the possibility of expressing cancer 
cells from severed lymphatic vessels, thereby incurring the risk 
of inoculating the wound. 

Relative Importance of the Several Steps. — It would, of course, 
be profitable to know just what each step in the ^'completed" 
operation has contributed to the sum total of cures. I think 
that we may rightly use such a term, as operative measures 
have become about as extensive as they well can be if indeed 
they have not reached the very Ultima Thule of justifiable 
surgery. This can never be known definitely. Valuable in- 
formation, however, is gained by taking the statistics of the 
best men of different decades and contrasting, so far as is 
practicable, the differences in their methods of operating. 
The first statistics of real value were those of Gross in 1880, 
compiled largely from the Danish, German and Austrian 
surgeons, who were the first to recognize the possibihties of 
Moore's operation; these yielded 9.05 percent of cures pass- 
ing the three year limit without regional or internal recur- 
rence. At this time the breast was incompletely removed 
because a small incision was made, the axilla was not opened 
unless palpably the site of metastasis, and then only a few 
enlarged glands were pulled out by blunt finger dissection. 

The next papers of great importance were published in 1888 
by Gross and Sir Mitchell Banks respectively, and it will be 



Carcinoma. 281 

seen that these surgeons reach the same theoretical and prac- 
tical results, 21.5 and 2 1 . No two men ever operated more alike. 
Both made a large wound, both removed the pectoral fascia, 
neither sacrificed the muscles, and both did a fairly good dis- 
section of the axilla; very good at the base, indifferent at the 
middle, and wanting at the apex or space of Mohrenheim. 

W, T. Bull, in 1895, pubhshed his own statistics in 118 cases, 
and attained somewhat better results than Gross and Banks 
had done (26.6 percent of cures). No series of cases had ever 
been more carefully and conscientiously followed up, and such 
results in the practice of this thoroughly well-known, conser- 
vative, and able surgeon did much to give an impetus to radical 
operations. Moreover, he stated with greater definiteness the 
axillary condition in his cases than others had done, and 
measured more accurately its effect upon the result of operation. 
His method of operating was very similar to that of Gross and 
Banks in every respect save one — he did a much better and a 
more thorough axillary dissection than either of them and 
removed so far as it was possible, without sacrificing the muscles, 
everything en masse. Therefore, it would seem fair to state 
that his additional five percent of permanent cures was due 
to more thorough work in the axilla. 

Having seen all three operate and knowing that each did 
exactly the same operation up to this step, I am convinced that 
Bull was entitled to the advantage shown by his statistics. 
Hence, we are, I think, amply warranted in saying that a fair 
axillary dissection will save double the number of cases (21.5 
percent) that will follow removal of the breast alone (9.5 per- 
cent) and that a good axillary dissection will save an additional 
five percent (26.6 percent) of such patients. Of Bull's 
cured patients 40 percent had decided axillary involvement 
before operation. Of the entire number operated more than 
61 percent had axillary involvement. 

Halsted has just published a report of 232 cases operated 



282 Diseases of the Breast. 

upon by himself and assistants in the Johns Hopkins Hospital. 
There were 38.3 percent free from recurrence three years 
or longer. In 14 cases metastasis appeared later than three 
years; in two, more than six years after operation and in one 
eight years after. 

This last report of Halsted is very satisfactory, inasmuch 
as his operation has now been on trial for 16 years. It also is 
instructive as pointed out under prognosis in showing clearly 
the advantage from early operation before there is involvement 
of the axilla. 

It will be interesting to see, should the theory of Mr. Handley 
meet with general acceptance and his suggestion for still more 
extensive operative measures be followed out in practice, if 
the permanent results warrant the increased primary risk. 

Technique. — As a complete operation for carcinoma of the 
mammary gland is one of some magnitude, due preparation 
should be given the patient beforehand. A general bath should 
be taken the evening before, it being followed by a careful 
shaving of the axilla, and the skin of the thorax, axilla, and arm 
thoroughly cleansed with antiseptic soap, bichloride solution 
I -1 000, ether and alcohol. Then the breast and adjacent 
parts involved in the operation are to be covered during the 
night, and up to the time of operation, with aseptic gauze. 

A mild purge of calomel is taken the afternoon or evening 
before, and if the bowels have not acted freely by 7 A. M. the 
day of the operation, an enema is given. Free catharsis is 
to be avoided, as these patients are frequently old, and excessive 
purgation may add to the shock usually incident to so pro- 
longed an operative procedure. 

The operation should preferably be set for 10 A. M., when the 
light is good — a necessity for a thorough axillary dissection. 
Prolonged operations in the afternoon must at times be fin- 
ished by artificial light. Moreover, they occasion a day of 
anxiety to the patient. 



Carcinoma. 283 

The temperature of the operating room should not be less 
than 72° F. and it is better to either place the patient upon a 
heated table or surround her with hot water bottles, being care- 
ful, of course, that burning of the skin does not occur. My 
invariable custom is to administer ^ to J of a grain of morphia 
with Tw of atropine hypodermatically one hour before beginning 
ether. This, I am convinced, tranquilizes the patient, lessens 
the amount of the anesthetic, minimizes shock, and materially 
contributes to post-operative comfort. The preliminary hypo- 
dermic is particularly called for if there be, as is so often the 
case, accompanying bronchial, cardiac or renal complications. 
The ether is always given slowly and by the drop method. 

The operating room should be well lighted, and if the day 
is cloudy a good electric light will materially aid in the axillary 
dissection. 

Besides the anesthetist, three assistants are necessary. The 
first assistant stands opposite to the operator, giving necessary 
assistance at every stage of the operation. He should be ex- 
perienced, collected, and thoroughly familiar with the various 
steps of the operation, for upon him largely will depend both 
the rapidity and thoroughness of the work. The second assist- 
ant stands on the same side as the operator, holding the arm 
and moving it from time to time as requested. The third 
assistant handles the instruments, and I find that a nurse is, 
as a rule, defter in picking up forceps, ligatures, threading 
needles, etc., etc., than the average house surgeon. Always a 
little, and sometimes a great deal of time, can be saved in this 
operation by a good third assistant. All should wear rubber 
gloves. A fourth assistant may be held in reserve in the event 
of pronounced shock, so that enteroclysis or hypodermoclysis 
may be promptly given without in any way delaying the oper- 
ation. This rarely, though sometimes, is necessary. 

Instruments. — At least two, preferably three, very sharp 
scalpels, two dozen hemostatic forceps, smooth and toothed 



284 Diseases of the Breast. 

dissecting forceps, large and small straight scissors, large and 
small curved scissors, Allis's or Mayo's blunt dissector, retrac- 
tors large and small, straight and curved needles, and a fenes- 
trated rubber drainage tube should be at hand. 

As skin grafting is so often required, either a sharp razor, 
or, what is better, a medium size amputating knife, tenacula 
and two sterilized blocks of wood for making the skin of the 
thigh tense should be in readiness. It is unnecessary to prepare 
the thigh for grafting before the operation, as it is quickly 
done when necessary by the fourth assistant without delaying 
matters, and if done beforehand disturbs somewhat the mental 
tranquility of the patient and emphasizes in her mind the 
magnitude of the operation. She should be told, however, 
that it may be necessary. 

Ligatures. — I prefer fine Pagenstecher for- ligatures. Silk, 
of course, will answer very well, but the tensile strength of 
linen is greater and it is as well or better taken care of by the 
tissues. Catgut prepared by either the Bartlett or Claudius 
method may be used should a strictly absorbable material 
be preferred. 

Sutures. — For closing the wound I prefer horse hair, using 
the continuous suture after the buttonhole method, unless there 
is too much tension, in which event supplementary interrupted 
sutures of Pagenstecher or silk are placed where they are most 
needed or used throughout. 

Dressing. — An abundant dressing of sterile gauze should 
cover the wound, thorax, axilla, arm, and neck. The dressing 
should be so applied as to make firm pressure, in the axilla 
especially, so as to obliterate any dead space. This is of much 
importance and greatly enhances the chances of primary union. 
As the dressing must be changed at the end of 24-48 hours, so 
that the drainage tube may be removed and dry gauze sub- 
stituted for that previously used, which will be found quite 
wet in the vicinity of the tube, plaster-of-Paris or other imper- 



y 



M- 



i 



PLATE XLIll 



**»;•«. 




Paget's Disease ot the Nipple 



Carcinoma. 285 

meable dressings should be omitted. They are quite unneces- 
sary, their apphcation always time-consuming, and it may be 
a matter of moment in the event of secondary hemorrhage to 
reach and open the wound as quickly as possible. Moreover, 
they prevent the prompt recognition of hemorrhage, save by the 
symptoms, which means that a great, perhaps a lethal amount 
of blood might be lost before the nurse would suspect what 
was wrong. 

As soon as the dressings are applied the patient should be 
placed on a carriage covered with warm blankets and quickly 
removed to her room, the temperature of which should be at 
least 75° F. — preferably 80°. 

The axillary or rectal temperature should at once be taken 
and will usually indicate a fall of several degrees. An axillary 
temperature of 95° is by no means rare and I have often seen 
it less. As a rule nothing further will be required. In the 
event, however, of a markedly subnormal temperature accom- 
panied by other symptoms of shock, an enema of hot coffee 
and saline solution should be given, the foot of the bed elevated, 
and a further hypodermatic injection of atropine administered, 
accompanied by morphia if the patient is suffering pain. In 
the most severe cases hypodermoclysis with adrenalin should 
be given in the thigh, so as not to disturb the dressing over the 
thorax. 

For strychnia as a remedy in shock I have little appreciation 
and believe that in many, perhaps most, cases, it is harmful. 
It is only in the relatively rare cases where the pulse is slow 
and wavering, the shabby pulse as it has been called, that it is 
desirable to increase the frequency and force of the systole by 
strychnia. Then it acts favorably and promptly. In the small 
and frequent pulse so usual in shock, strychnia exaggerates the 
condition and "lashes the tired horse." 

Even though there be no shock, it is my invariable custom 
to order that enteroclysis be given every four hours during the 



286 Diseases of the Breast. 

first 48 hours, or until the patient is able to take plenty of 
fluids by the stomach. Six to eight ounces of normal salt 
solution with a desertspoonful of the infusion of digitallis will 
usually be retained without difficulty. This quenches thirst, 
flushes out the kidneys, and in every way subserves the 
patient's comfort. I consider it too helpful to be omitted in 
any case. If there is not great tension upon the flaps the 
preliminary dose of morphia may be all that is necessary. It 
is not unusual, however, for a second dose to be required in 
the evening or night following the operation if tension upon 
the flaps has been made in closing the wound. 

Operation. — I prefer ether anesthesia given cautiously by the 
drop method, though not infrequently use chloroform if there 
is contra-indication to ether. It is of importance in the first 
instance that the anesthetist, before beginning the ether, adjust, 
if it has not already been done, a rubber cap to the patient's 
head, the hair being done up on top. This keeps the hair 
from possibly getting into the wound. 

Secondly, he is instructed to lighten the anesthesia from 
time to time after the incisions through the skin have been 
made. Light anesthesia suffices during the occasionally 
prolonged axillary dissection. 

Thirdly, he should be warned to keep his own and the 
patient's head turned to the opposite side so as to prevent 
their breathing into the wound or possibly infecting it with 
saliva, vomitus, etc. He, as well as all others taking part in 
the operation, should wear a mask and take every precau- 
tion that other assistants do to insure sterility. It would 
appear better to [have a screen or shield, which will effect- 
ually prevent either the patient or the anesthetist from con- 
taminating the wound. It is, however, inconvenient; prevents 
the operator from looking into the face of the patient 
and the anesthetist from observing her movements, a hint 
for deeper anesthesia, or from seeing the dark color of the 



Carcinoma. 287 

blood incident to profound narcosis. Without a most ex- 
perienced and trustworthy anesthetist, the screen is a disad- 
vantage, as infection of the wound by either patient or anes- 
thetist must be infrequent and the risks of anesthesia are 
certainly increased by the use of the screen. 

I shall describe the steps of the operation I now do, and 
which, I think, embraces the good features of the most ap- 
proved and accepted procedures for carcinoma of the breast. 
A straight incision is made beginning one inch below the clavicle, 
two finger-breadths from and parallel with the sulcus between 
the deltoid and the clavicular portion of the pectoralis major. 
It extends well below the free edge of the pectoralis major 
muscle, and in extent will usually be from five to six inches or 
more, according to the stature of the subject and the size of the 
breast. (Plate XLIII A.) It is rapidly carried down through 
skin and superficial fascia to the fascia covering the great 
pectoral muscle. No hemorrhage of consequence is encount- 
ered thus far. I prefer to place this incision not too close to 
the arm, for, in my judgment, incisions extending on to the 
arm result in cicatrices, which often seriously interfere with 
the future usefulness, and less frequently cause edema of the 
limb. 

The index finger of the left hand is now introduced beneath 
the lower border of the tendon of the great pectoral muscle 
and made to emerge above its upper border, or in the interval 
between the costal and clavicular portions, if one wishes to re- 
move only the costal origin of the muscle, and division of the ten- 
don effected at or near its insertion into the humerus. This may 
be facilitated by dissecting up the external flap slightly and using 
retractors. I myself see no reason for removing the clavicular 
portion in the average case, and, therefore, leave it unless the 
growth is peripheral and in the upper hemisphere. Then unques- 
tionably the entire muscle should be sacrificed. (Plate XLIV.) 
Only a slight dissection will be necessary to discover the lower 



288 Diseases of the Breast. 

edge of the tendon of the pectorahs minor. This should be 
clearly identified and separated from the fascia covering the 
tendon and below it. Otherwise the long thoracic artery 
which runs in the fascia parallel with and just below the 
tendon may easily be wounded. 

The index finger is now introduced underneath the muscle 
and made to emerge at its upper border. Lifting up the 
muscle, the tendon is made tense and prominent, so that it 
can readily be seen that no other tissues are included with the 
tendon. The acromio-thoracic artery runs just above and 
parallel with this tendon, and, being a branch of considerable 
size, might cause some little embarrassment if it were cut at 
this stage of the operation. It is divided at its insertion into the 
coracoid process. (Plate XLV.) Therefore, we have the acromio- 
thoracic artery parallel with and just above the upper border 
of the minor pectoral tendon; the long thoracic parallel with 
and just below its lower border. Both can easily be avoided 
if care is taken. I have never as yet wounded either vessel, nor is 
there excuse for doing so. Both muscles retract inward as soon 
as their respective tendons are severed. This at once uncovers 
the axilla and makes its subsequent thorough dissection easy. 
The costo-coracoid membrane is now opened and largely 
sacrificed, which gives ready access to the subclavicular fat 
at the apex of the axilla — in the space of Mohrenheim. In 
removing a part of the costo-coracoid membrane, the cephalic 
vein at the upper and outer aspect of the wound must not be 
wounded. There is also in the fascia a branch of the acromio- 
thoracic which, with its accompanying vein should be clamped 
and tied. A nerve supplying the pectoral muscle may as well 
be sacrificed now, as it necessarily must be later on when the 
muscles are removed. (Plate XLVI.) 

The dissection is begun at the apex of the axilla and must be 
most carefully conducted lest injury be done to either the 
axillary vein or the acromio-thoracic artery. It should be 



Carcinoma. 289 

from above downward, though this is perhaps somewhat more 
difficult than making the dissection from below upward. 

In the removal of the fat and fascia in the upper third of 
the axilla, the finger, covered by several thicknesses of gauze, 
will be all that is necessary. Instruments are rather dangerous, 
unless used most cautiously. Moreover, they are unnecessary. 




Fig. 36. — Allis's blunt dissector. 

I now carefully make an incision through the fascia to the 
outer side of the axillary vessels simply to start the dissection 
from without inward. This is made to the extent of the 
lower two-thirds of the axilla and not in the upper third where 
it is dangerous to cut. I continue the dissection largely with 
gauze, but Allis's or Mayo's blunt dissectors may be used 




Fig. 37. — Mayo's blunt dissector. 

freely and are most helpful. (Figs. 36 and 37.) Occasionally 
a cut with scissors or a sharp knife facihtates the dissection. 
The instrument of Charles H. Mayo is more than a blunt dis- 
sector for it can also be used as a scissors and is most valuable 
in economizing time, making a change of instruments unneces- 
sary. 

As the sheath and fat are removed from the vessels we come 

down upon the acromial, long and alar thoracic branches, 
19 



290 Diseases of the Breast. 

and the subscapular branch of the axillary artery, in the 
order named, from above downward, which, with their accom- 
panying veins are to be carefully clamped in two places and 
divided between. The proximal ends are ligated. In this 
way the subsequent hemorrhage is materially lessened; in fact 
it is surprising how little blood will be lost during so prolonged 
and extensive a surgical procedure. 

The enlarged lymphatic glands will usually be found at 
the base of the axilla between the latissimus dorsi, teres major, 
and subscapulars muscles posteriorly; the serratus magnus 
internally; and inferior to a line formerly indicated by the 
situation of the lower border of the pectoralis minor. The 
midaxillary and subclavian glands may, however, be infected. 
All such enlarged glands and surrounding fat should be care- 
fully dissected from the several muscles, and to do this best, 
the fascia covering the muscles should be sacrificed. In fact, 
so thorough should be the axillary dissection that nothing is 
left on its inner aspect save the posterior thoracic or nerve 
of Bell; on the posterior aspect only the long subscapular 
nerve, and superiorly, possibly the superior thoracic artery, 
if it arises as an independent branch high up on the first portion 
of the axillary. In such circumstances it is impossible, in 
my judgment, to reach it with safety. It is so deeply placed 
that there is great danger of doing serious damage to the vein 
and artery, the former particularly, if an attempt is made to 
secure the vessel at its root. I have convinced myself by work 
in the dissecting room that it is at least a hazardous if not an 
unwarranted procedure. In this opinion my friend Dr. 
Charles W. Bonney, of the Anatomical Staff of the Jefferson 
Medical College, who has made many dissections at my request, 
fully concurs. It is a small branch and negligible so far as 
subsequent hemorrhage is concerned. Moreover, it not 
infrequently arises conjointly with the acromio-thoracic, and 
in such cases is easily secured with the other vessel. 



Carcinoma. 291 

A thorough dissection .of the axilla can usually be finished 
in twenty minutes, and is entirely accomplished through 
the single straight incision. It should invariably be from 
above downward, without inward, and en masse. A piece- 
meal extirpation is not to be considered. Patience, a good 
hght, and working with blunt dissectors, all insure a safe and 
reasonably speedy dissection of the axilla. As we have said, 
sharp instruments are not to be used at the apex of the axilla, 
but may materially facilitate the dissection at its base. Acci- 
dental injuries to the vein are not common, and when occurring, 
are, if practicable, to be treated by lateral ligature or suture. 
(Plate XLVII.) 

The advantages accruing from attacking the axilla before 
removing the breast are to me manifest and self-evident. 
In the first place, we may find, as S. W. Gross taught during 
my internship in Jefferson Hospital ('79-80) that the axilla 
may be so extensively involved that a complete eradication of 
the growth is impracticable and further operative steps in- 
judicious. True it is, however, that many cases which Gross 
would have considered inoperable, can be successfully dealt 
with at the present time, because of the more thorough axil- 
lary operation since division of the muscles became a routine 
procedure. 

Another and a more important reason (and this I have 
insisted upon in several of my former papers) for working 
from, instead of toward, the axilla, is that by so doing we avoid 
expressing cancer cells into adjacent, even possibly remote 
tissues. Therefore, the breast should not be handled, massaged 
or in any way disturbed until the axillary dissection has been 
finished and the completion of the operation is near at hand. 
In my opinion, this is one, indeed the best reason for not 
working from sternum to axilla, and for reversing the technique 
of Halsted and many others. 

There is still another reason for makino; the axillarv dissec- 



292 Diseases of the Breast. 

tion the first instead of the last step in the operation; hemor- 
rhage is certainly very much less when the vessels are ligated 
at their origin, as first advised and practised by Willy Meyer. 
Therefore, the time of the operation is shortened and shock 
necessarily minimized. 

It is of interest to note that injuries to the axillary vein were 
comparatively frequent and serious prior to the time when 
the muscles were resected and an aseptic technique was rigidly 
observed. I personally witnessed three such accidents in the 
early days of mammary operations, and all were fatal from 
sepsis. I have never wounded the vein myself, but have 
deliberately resected it three times, removing in one instance 
at least four inches on account of evident infection of its walls, 
as it passed directly through a large mass of cancerous glands. 
There was no subsequent edema in any of my cases. I con- 
fess that I was quite apprehensive the first time I was compelled 
to resect the vein, as I was not then advised as to its comparative 
safety. Subsequently I had reports of resections in 24 cases 
in the practice of other surgeons. All the patients recovered. 
In only four of them was there resulting edema and in each 
of these it was both^slight and transient. 

While accidental injuries to the vein, when practicable, 
should be treated by either lateral ligature or suture, we have 
shown that either ligation of the vein in continuity or its resec- 
tion can be practised with comparative safety. 

The axillary dissection having been accomplished, it now 
remains to complete the skin incision, which is made by 
beginning at the middle of the initial incision and circum- 
scribing the entire breast with either a circular, oval, or broadly 
elliptical incision. The circular incision is only to be advised 
in a central or subareolar growth. Generally I employ an egg- 
shaped incision which is an oval so broad that its greater 
diameter is at least five inches; it will be six inches or more if 
the breast is a large one, or the cancer is situated peripherally, 



Carcinoma. 293 

for the skin incision must under no circumstances come nearer 
than two inches to the edge of the growth. (Plate XL VIII.) 

The knife should not be carried straight down to the muscles 
beneath, but slanted in such a manner as to divide the sub- 
cutaneous tissue or the para-mammary fat at least two 
inches further out than the skin has been cut, which will 
practically take it up to near the clavicle superiorly, well 
beyond the sternum internally, below the border of the 
great pectoral inferiorly, or well on to the external oblique 
and rectus. 

While this can be done by the experienced operator by a 
method of subcutaneous transfixion, using for the purpose a 
straight, rather long and sharp pointed knife, I prefer to use 
an ordinary scalpel, the skin being retracted as I do so by a 
careful and competent assistant. In this way just the amount 
of subcutaneous tissue may be left adherent to the skin to insure 
its future vitality. Moreover, I prefer to ligate at once any 
vessel which has been cut. The superior thoracic, if not 
previously secured at its origin, will certainly be cut in under- 
mining superiorly and the perforating branches of the internal 
mammary of the opposite side may be severed when the flap 
is being fashioned internally. I have seen severe hemorrhage, 
in fact an unwarranted amount of blood lost by this trans- 
fixion method, the removal of the breast being completed before 
any vessels were tied. 

During three trips to Great Britain during the last five 
years, I was privileged to see many operations for mammary 
cancer, and was impressed with the facility and thoroughness 
with which undermining is practised there. The British 
surgeons excel all others in this step of the operation. The 
late Sir Mitchell Banks, of Liverpool, Mr. W. Sampson Handley, 
of London, and Mr. George L. Chiene, of Edinburgh were 
particularly deft in its execution. Such extensive under- 
mining of the skin not only removes any outlving or rudimentary 



294 Diseases of the Breast. 

portions of the mammary gland, but facilitates the removal 
of the fascia covering the opposite pectoral muscle internally, 
that of the rectus and external oblique inferiorly, and that of 
the latissimus dorsi externally. 

Mr. Handley, of London, considers this step of the operation 
one of, perhaps the most important, on account of the frequency 
with which invasion of the peritoneal cavity occurs as the 
result of permeation of cancer cells along the fascial planes 
of the muscles — the rectus particularly. He, therefore, extends 
his incision downwards in the direction of the umbilicus, so 
that the fascia covering the rectus may be removed to a still 
greater extent than has been my practice. Possibly this is 
wise, and, as has been said elsewhere, I am inclined to adopt 
his suggestion in the future and to still further extend my 
wound inferiorly by making the smaller end of the oval some- 
what more pointed. I do not agree with him, however, in 
thinking that the removal of the deep fascia is far more to be 
desired than the free removal of skin. Quite the reverse. 
I insist first and foremost that we should begin with a wide 
removal of skin, and in deference to what seems to be sound 
logic and good pathology, am willing to end with a jreer 
removal of the deep fascia over the rectus. My dissections 
have for years been jree. 

Undermining also insures approximation of a very large 
wound. The breast with its axillary tail still attached, the 
pectoral muscles, para-mammary fat, and deep fasciae, are all 
lifted up on the costal wall, as shown in Plate XLIX, prelimin- 
ary to cutting the costal attachments of both pectoralis minor 
and major. In cutting the attachments of the great pectoral 
muscle, the perforating branches of the internal mammary 
will be severed, and should be promptly seized with forceps. 
In undermining the flap internally, the perforating branches 
of the opposite side may be cut and require attention, as we 
have already said. They will certainly be severed in dissecting 



Carcinoma. 295 

up the fascia over the sternal end of the opposite pectoral 
muscle and should at once be clamped and ligated. 

We now have a very large wound; over the chest the inter- 
costal muscles are exposed ; inferiorly the external oblique and 
rectus; posteriorly the latissimus dorsi, teres major, and sub- 
scapularis, and the long subscapular nerve ; at the outer aspect 
of the chest (the inner aspect of the axilla) the digitations of 
the serratus magnus and the nerve of Bell. (Plate L.) 

It will be seen from Plate L that a part of the pectoralis 
major and minor muscles is left at their origin. This is 
done for two reasons: It prevents adherence of the skin to 
the ribs and makes a good bed to plant grafts in case grafting 
is necessary. It is a mistake to leave the ribs bare and delays 
healing of the wound. 

If the growth is situated in the sternal hemisphere of the 
gland, the oval is reversed, so that its smaller end is at the axilla. 
By so doing less chance is taken of leaving behind infected skin. 

In case the tumor is situated in the upper hemisphere, it 
is my invariable custom to make an incision above the clavicle 
and to carefully explore the posterior triangle of the neck. 
It should extend from the posterior border of the sternomastoid 
to the anterior border of the trapezius, and be preceded by pull- 
ing the skin downwards so as to prevent premature injury to 
the external jugular vein. I prefer to make a separate incision 
for this purpose rather than to extend the original wound into 
the neck, as I see only a theoretic reason for doing this. Little 
good is accomplished by it, the scar made is unsightly and its 
subsequent contraction disadvantageous. A straight incision 
on the clavicle retracts above it and will scarcely be noticed. 
Cutting through the skin, superficial fascia, platysma and 
deep fascia, the omohyoid is exposed, held upward by a re- 
tractor, and the triangular space which it bounds carefully 
freed of fat and enlarged glands if any be present. The ex- 
ternal jugular vein is usually resected. I have rarely encount- 



296 Diseases of the Breast. 

ered supra-clavicular involvement, yet believe it has been 
demonstrated that this step of the operation cannot safely be 
dispensed with, for the reason previously given, viz., that in 
malignant growths situated in the upper and peripheral portions 
of the breast, a chain of lymphatic vessels passes from the breast 
over the clavicle to empty into glands in the posterior cervical 
triangle. 

In tumors of the lower hemisphere, I never explore the neck. 
The supra-clavicular incision is also made in case I encounter 
infection of the glands or fat in Mohrenheim's space. If the 
glands just below the clavicle are involved, it is reasonable to 
infer that those just above it may be infected; at least it is 
unwise to infer that they are not. I have not found exploring 
the neck to add materially to the shock or danger of the opera- 
tion and, moreover, I am convinced that now and then a 
case is saved by taking this additional precaution. I have 
never, however, divided the clavicle nor do I believe it neces- 
sary; neither do I feel that this step of the operation should 
contemplate removing a portion of the subclavius muscle or 
forcing a mass from the neck to the chest behind the clavicle, 
as such manipulations may express cancer cells in the event of 
cervical infection. Such dissections may undoubtedly be 
done with relative safety by the patient and skillful operator, 
but after all do not result in an amount of good to justify the 
risk — immediate and potential — inherent in them. 

Any slight or extensive oozing can be quickly stanched by 
the application of hot water at a temperature of 120^. I not 
only consider this the best hemostatic, but feel that it is ad- 
vantageous in the event that our manipulations may have 
expressed cancer cells on any part of the wound. Therefore, 
freely douching the part, whether it is bleeding or not, is 
desirable. Any vessel of sufficient size to require a ligature is tied 
with fine Pagenstecher ; others are twisted. Complete hemos- 
tasis is insisted upon. It is surprising how few ligatures will 



Carcinoma. 297 

be necessary if the large branches already mentioned have 
been ligated at their origin. I consider it important to 
thoroughly arrest hemorrhage before beginning the suturing, 
for at the best we must expect a considerable amount of serum 
to be poured out into such a large wound. 

Closure of the wound is begun where it was started — that is, 
near the clavicle, and can be accomplished by either inter- 
rupted or continuous sutures. I prefer several interrupted 
Pagenstecher sutures, which give the necessary support and 
act as stays, and for accurate approximation, where the 
tension is not too great, supplement them with a continued 
suture of horsehair after the buttonhole method. In the 
event of much tension, interrupted sutures are used throughout. 

The first incision having been sutured, closure of the oval or 
circular (whichever has been employed) portion of the wound 
is begun at the sternal end. When we have advanced one- 
third of the distance between the two extremes of the second 
and larger incision, it will be easy to tell whether or not approx- 
imation of the flaps can be accomplished with facility; if not, 
the suturing should be stopped at this point, begun at the other 
end, and carried out to the extent of one-third of the incision; 
the central third of the wound is left unsutured and is im- 
mediately covered by suitable grafts taken from the thigh 
after the method of Thiersch. It has been rarely necessary 
for me to graft of late, for even though a very large wound is 
made, the extensive undermining makes approximation easy. 
(Plate LI.) The length of the horizontal suture line is twelve 
inches or more. I have never found it less. 

A vast majority of surgeons employ drainage. I have nearly 
always done so and still believe it to be best in the majority 
of instances. A tube is inserted at either angle of the wound; 
one posteriorly to drain the axilla, the other anteriorly extend- 
ing down between the costal margin and umbilicus. I do 
not question that such a wound may be safely closed in many 



298 Diseases of the Breast. 

cases without drainage and occasionally have done so without 
cause for regret. If, however, the breast is large, or the work 
in the axilla has been unusually prolonged on account of exten- 
sive axillary involvement, requiring a difhcult and tedious 
dissection, I think it safer to drain. I find that the custom 
of draining such wounds is practically universal among Amer- 
ican surgeons. Only three of a large number of surgeons com- 
municated with do not employ drainage. 

An abundant dressing of aseptic gauze is now applied in 
such a way as to obliterate the axillary space. A wedge-shaped 
pad is placed between the arm and chest and the arm bound 
firmly to the side by broad adhesive straps for at least 24 hours. 
I see no advantage in applying the dressings so that the arm 
will be at a right angle to the body. Tension upon the flaps 
is increased by such a position, hemostasis is certainly not 
favored by it, and the axillary space is made to gap, thereby 
inviting a subsequent collection of serum which may give 
trouble. At the end of 24 hours the arm is released, and, if 
painful, rubbed with alcohol. It is not included in the sub- 
sequent dressing. 

If we now examine the specimen, it will be seen that the 
para-mammary fat has been removed to a very much greater 
extent than has hitherto been usual in breast operations. 
In fact so much has been taken away that there are two circles 
or ovals; one, represented by the skin itself, which is five or 
more inches in diameter; another, and very much larger circle 
or oval, by the fat and deep fascia. In other words, perhaps 
double the extent of the skin removed. 

Plate LII shows the outline of the incisions and the line of 
the cicatrix. 

The assistant holding the arm should be careful lest hyper- 
extension be made at any time during the operation. This 
can easily be done after the pectoral muscles are cut and may 
possibly result in monoplegia. At least this has been con- 



PLATE XLIII A, 




PLATE XLIV. 




PLATE XLV. 




PLATE XLVI. 




PLATE XLVII. 




o 



PLATE XLVIII. 




PLATE XLIX. 




PLATE L. 




PLATE LL 




a 



PLATE LII. 




c 


Tt 










tu 










;_, 


(i; 


U 








-n 










o 


C 


CJ 


o 






•2^ 



w 



rt ^ ^ 



r a 



M 



■ill 

ill 



n, > 



M bp 



Carcinoma. 319 

sidered to be the cause of such paralysis after breast operations. 
I have never known it to occur in any of my cases. Still, 
this accident has been reported sufficiently often to v^arrant 
explicit instructions being given to the assistant before 
the operation is begun. In my judgment, monoplegia follow- 
ing such operations is more likely to result from pressure on 
the limb posteriorly, injury being caused to the musculo-spiral 
nerve. I have known this to happen once or twice, but never 
in a breast operation, and it has always been due apparently 
to the pressure resulting from the arm resting upon or hanging 
over the sharp edge of the operating table. 

Post-operative Treatment. — The patients usually feel well 
enough to sit up on the third day. I generally allow them 
to do so in bed and have occasionally permitted those doing 
best to sit in a chair for a part of the morning and afternoon. 
I prefer, however, to keep them in bed until the fifth day. 
One of my patients left the hospital on the sixth day, going 
to her home in an adjoining state. She felt perfectly well 
and able for the journey. I do not think that I would have 
countenanced her leaving the hospital so soon had the weather 
not been very hot and her home far more comfortable than 
the hospital. 

My patients often leave the hospital in ten days or as soon 
as the sutures are removed. Some remain a fortnight; ex- 
ceptionally two and a half or three weeks may be required if 
either skin grafting has been necessary or a part of the wound 
has been allowed to granulate. 

The drainage tubes are removed at the change of dressings 
at the end of twenty-four hours. They are inserted, as for- 
merly stated, at either angle of my wound; one posteriorly to 
drain the axillary space; the other anteriorly which extends 
well down to midway between the costal margin and the um- 
bilicus as serum is likely to accumulate here. I formerly made 
a posterior stab and inserted a drainage tube into the axilla only. 



320 Diseases of the Breast. 

I ignore all suggestions which have been made to keep the 
arm in this or that position so as to increase its future usefulness. 
Some believe moderate abduction is necessary; others think 
that the arm should be at a right angle to the body; others 
still that a triangular splint should be used. All such sug- 
gestions and devices have been thought necessary on account 
of a definite restriction in the movements of the arm after 
certain operative procedures, where the cicatrix extends from 
the chest wall to the arm, and necessarily fetters it subse- 
quently more or less. A very great majority of such incisions- 
do cause subsequent trouble with the arm and, therefore, the 
numerous suggestions and expedients for preventing it and for 
mobilizing the scar. 

The cicatrix following the operation I employ is entirely 
on the chest wall, does not extend to the arm, or in any way 
encroach upon the axilla;] therefore, its "mobilization" is 
entirely a negligible quantity. I release the arm on the second 
day or when the drainage tubes are removed and the dressings 
changed. Subsequently the patient is allowed to move it at 
will. 

Another serious objection which I have found to the incisions 
which pass from chest to arm, or the reverse, is that the cicatrix 
has occasionally been responsible for a subsequent edema of 
the arm. 

I no longer have my patients complain of not being able to 
dress their back hair, or indeed anything that they were able 
to do before the operation. I do not see the slightest differ- 
ence in the relative usefulness of the two arms. I have had 
quite a number of my patients complain of limitations in the 
movements of the arm when I employed Warren's operation. 
In two cases, the bridge of skin from arm to thorax was so 
pronounced that I subsequently, months after the operation, 
divided it, releasing the arm, and also lessening the pain 
caused by the contraction of the scar. In a third and more 



Carcinoma. 321 

marked example of the kind, I wanted very much to do it, 
but the patient would not permit me. 

I wish to say definitely that any limitation in the movement 
of the arm is not due to the loss of the pectoral muscles, 
strange as it may seem, but in every case that I have seen is 
entirely due to a cicatrix following an incision unfortunately 
placed. 

I have two patients in whom both breasts have been operated 
on; one of them had the right breast removed five years ago 
for a scirrhus carcinoma with more than an average amount 
of axillary involvement. A very large wound was made after 
the method then employed by Prof. Warren, differing a little, 
but not essentially from the method which he now uses. Both 
muscles were sacrificed. Two years later a cyst appeared in 
the left breast. She being nearly fifty, having had cancer in the 
opposite breast two years previously and her mother having 
died of mammary carcinoma, I deemed it wise, and she 
requested me to remove the entire mamma. This was done 
and the fascia covering the great pectoral muscle removed 
also. I did not, however, sacrifice the muscles themselves. 
At the same time that the operation was performed on the left 
breast a bridge of skin which had fettered the right arm and 
had prevented her from "doing her back hair," also causing a 
moderate edema of the limb, was cut and considerable of the 
cicatrix excised. The resulting defect was covered by a 
Thiersch graft so as to prevent subsequent contraction. To- 
day she has a supple cicatrix, the edema has entirely passed 
away, and she uses her arm as well as she ever did; just as 
well as she does the left arm, notwithstanding that the muscles 
were sacrificed on the right side and spared on the left. 

I may state that this patient has been in my office within 
a week. Therefore, I speak advisedly both as to the local and 
general condition. She was never in better health in her life. 
The supra-clavicular operation was done in this case, but was 



322 Diseases of the Breast. 

found to have been unnecessary, as there was no infection above 
the clavicle. 

It has been my experience to see four cases of pneumonia 
following breast operations. Fortunately all have recovered. 
Three of them came early, within 72 hours after the anesthetic, 
and were presumably due to the ether, as they were catarrhal 
pneumonias. 

The last case I encountered two years ago when a patient 
doing splendidly up to the eleventh day, being about ready to 
go home, slept in a draft, and had an acute, frank lobar 
pneumonia, which delayed her convalescence several weeks. 
It was followed by phlegmasia in both limbs. This is the only 
time I have ever seen phlebitis following a breast operation. 
The patient made a complete recovery. 

The right breast was removed; the pneumonia was clearly 
confined to the left lung. The phlebitis began in the left leg 
about the time the pneumonia was subsiding; the right leg be- 
came involved a few days later, and both limbs had to be 
bandaged for some weeks afterwards. In time, however, the 
return to their normal condition was complete. 

There has been no recurrence of the malignant disease, and 
the patient is to-day in the very best possible health — much 
better, she states, than she has ever been before. 

Plastic Operations. — Various plastic procedures have been 
devised to fill in the defect caused by the extensive removal 
of the superficial structures in the complete operation for the 
removal of a carcinomatous breast. Chief among the earlier 
of these procedures may be mentioned the methods practised 
by Legueu and Graeve in France and Sweden respectively, 
by Mixter in this country, and by Franke in Germany. 

In order to cover in a defect caused by the ablation of an 
extensive recurrent carcinoma extending from the axillary 
line to the sternum, Legueu made a large flap containing 
the other breast and sutured it over the raw surface made by his 



Carcinoma. 3^ 

extensive dissection, thus transplanting the healthy breast. 
Graeve and Mixter performed similar operations for the same 
purpose. Franke's procedure differed from these in that he 
dissected out the healthy breast from the flap which he cuT, 
using only the skin and subcutaneous tissues, thereby doing 
away with the unsightliness of a single breast in the middle of 
the anterior thoracic wall. ; 

Of the plastic procedures popular in America, I consider 
that of J. Collins Warren the best, for this method is with- 
out the inherent danger of all other plastic procedures, inas- 
much as the skin is widely removed, the defect resulting there- 
from is covered by a cutaneous flap brought from below, a 
region which, in a majority of instances, will be farthest re- 
moved from the tumor, and, therefore, presumably healthy. 
In other words, the flap is cut last, and only to facilitate the 
closure of a wound sufficiently ample. I have employed this 
method frequently and with satisfactory results in the main. 
The one objection that I have sometimes found with it has been 
a resulting band of skin which subsequently fetters the arm 
somewhat in its movements and less frequently causes edema 
on account of the incision extending from the chest to the hu- 
meral attachment of the pectoralis major. 

Warren's operation is described by its originator practically 
as follows : 

"An incision is made from the anterior and outer margin of 
the axilla running a little above its upper border and the line 
of insertion of the pectoralis major muscle around the lower 
border of the breast to a point on the boundary line of the inner 
and lower quadrant. A second incision is made, beginning at 
the middle of the anterior axillary fold, gradually diverging 
from the first incision as it approaches the breast and, sweeping 
around the upper and inner margin of the organ, meets the 
first incision at its terminal point. 

"A flap is next marked out on the outer side of the pectoral 



324 Diseases of the Breast. 

region by dividing the skin on the outer edge of the wound, on 
a hne drawn first at right angles to the primary incision and 
then gradually sweeping around until it becomes parallel to it 
and terminates at a point a little below the level of the lower 
margin of the wound. (Plate IJII.) 

" In case there is infection of the cervical region, an additional 
incision should be made from the middle of the upper half of 
incision number two along the posterior border of the sterno- 
mastoid muscle to expose the clavicle and the posterior cervical 
triangle. This incision, if necessary, should not be made until 
a later stage of the operation. 

''The second step of the operation is the dissection of the in- 
teguments freely on all sides, the axilla included, from the sub- 
jacent adipose tissue. The axillary skin and the flap are thus 
dissected off on the outer and lower side of the wound, and the 
dissection on the median line is carried well over the margin of 
the sternum. This superficial dissection should also be carried 
upwards so as to expose the clavicle. (Plate LIV.) 

"The third stage of the operation is now begun. Beginning 
with the humeral insertion of the pectoralis major muscle, 
the forefinger of the left hand of the operator is slipped under 
the edge of the muscle from above downward and the muscle 
is divided a short distance from its insertion. (Plate LV.) 
The proximal end of the muscle is seized with hooks and pulled 
in the direction of its origin, while its fibers are separated from 
those in immediate contact with the clavicle. An assistant 
while holding the hooks gently draws the breast with the other 
hand in the direction of the epigastrium. A few touches with 
the- point of the knife expose the insertion of the pectoralis 
minor muscle. The finger is now hooked under this insertion 
and the muscle divided (Plate LVI). 

"When the assistant retracts the breast in the direction already 
indicated, the axillary region is freely exposed, and the thin 
fascia overlying the vessels being divided, the larger vessels 



Carcinoma. 325 

are readily identified. In this way the dissection of the axilla 
can be carried out with great precision, and the origin of all 
the large branches can be secured with a ligature (Plate LVII). 

^' As the dissection of the axilla approaches the clavicle, care 
must be taken not to cut through the superjacent fat that has 
been exposed by the earlier dissection, but to reflect it back 
in every direction toward the center of the mass so that the 
upper edge of the origin of the pectoralis major at the sternal 
margin is clearly identified. As the dissection proceeds down- 
ward and outward in the axilla, the adipose tissue must not 
be divided until the knife can come down upon the latissimus 
dorsi muscle. The greatest care must be taken not to separate 
any of the tissues from the included lymphatic glands or to cut 
into them. 

"A few sweeps of the knife separate the mass from the latis- 
simus dorsi muscle. The breast is now seized by the'operator 
and rapidly dissected off the thoracic wall from , without in- 
ward. The origin of the pectoralis minor is first divided, and 
the final act of the operation consists in severing the origin of 
the pectorahs major while the breast and attached tissue are 
firmly held away from the sternal margin. (Plate LVIII.) 

'' If deemed advisable to invade the neck, the incision already 
mentioned is made along the posterior border of the sterno- 
mastoid muscle. After cutting through the deep layer of 
the superficial fascia of the neck, the posterior border of the 
sternomastoid is pulled inward and the omohyoid is lifted up- 
ward. A thin fascia then presents itself, under which lies a 
pad of adipose tissue, in which one or more lymphatic glands 
are found. When the region has been properly cleaned out, 
it is possible to make the forefingers of each hand come in 
contact with one another beneath the clavicle. 

^'The closure of the wound in this operation has always 
been a difficult problem, since it has been decided that the 
whole integument of^the breast should be included between 



326 Diseases of the Breast. 

the incisions. Any method which permits of an easy approx- 
imation of the edges of the wound is out of date. The lower 
portion of the wound is the part where the edges are the most 
difficult to approximate. The free loosening up of the skin 
enables the upper portions to come easily together. 

"The flap made at the outer side of the wound is about the 
size of the human hand, and when first turned in seems to be 
totally inadequate for the purpose. To draw upon this flap 
is to endanger its vitality. Therefore, the suturing is begun on 
the outskirts of the wound at four different points, viz.^ at 
each end and on each side. A few stitches are taken at the 
axillary and at the sternal ends of the wound first. The flap 
is then turned in and held in place by a temporary stitch, while 
it is gradually pushed up into place from below by sutures firmly 
girding together the edges of the skin to which the flap was 
originally attached. Sutures should all be superficial, as deep 
sutures cut and do not give the skin included by them a chance 
to stretch. Plate LIX shows the wound as finally closed."* 

The margins of such an extensive wound cannot be approxi- 
mated, and for the purpose of covering it in, a flap is taken from 
the side of the thorax and turned up from the lower margin of 
the wound. An incision is made at the middle of the lower 
]ip and at right angles to it. The knife is carried in a gentle 
curve downward or upward as preferred, or in both directions, 
and the flap or flaps can be so spread out as to cover in the 
greater portion, if not all, of the exposed surface. 

In the procedure recently devised by Jabez N. Jackson, of 
Kansas City, Missouri, the skin incision is begun at a point 
about one and one-half inches below the clavicle in the sulcus 
between the deltoid and pectorahs major muscles. From this 
point the incision is carried in a straight line along the sulcus^ 
parallel to the 1 inner border of the deltoid muscle, until it 
reaches the lower border of the pectoral fold as it terminates in 

* Annals of Surgery, December, 1904. 



PLATE LIII. 




Showing skin incisions in Warren's soperation. {Annals of Surgery.') 



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Showing appearance of wound ^after closure in Warren's operation. 
(Slightly modified owing to an unusually large wound.) 



Carcinoma. 341 

the arm. As this incision is carried down through the skin and 
superficial fascia, it exposes the fibers of the pectorahs major 
converging well to its tendinous insertion on the humerus. 
At the lower point of this incision, where it curves along the 
under border of the pectoralis major, the index fmger is now 
shoved up underneath the pectoralis major muscle and brought 
out again at its upper border, so that the entire muscle is thus 
hooked up on the index finger and by blunt dissection separated 
out to its tendinous insertion. The tendon of the muscle is 
then divided close to its insertion into the humerus. The 
muscle immediately retracts toward the chest and exposes, 
underneath, the pectoralis minor muscle imbedded in its fascia, 
which above runs to the clavicle, and below spreads out over 
the chest wall. It is also divided close to its insertion, and, 
like the pectoralis major, retracts at once, thus giving a good 
exposure of the axillary space. If necessary the horizontal in- 
cision may be begun before the axilla is cleared out. 

After the dissection of the axilla has been finished, the orig- 
inal skin incision is completed by carrying the horizontal in- 
cision over to the chest and outlining the outer half of the ellipse, 
which should parallel the original incision so as to permit the 
flap to be raised and turned upward toward the clavicle, thus 
giving a deeper exposure of the attachments of the pectoral 
muscle above and in front. It is important that a small tenac- 
ulum forceps should be placed at each angle of this flap when 
it is completed; it is then wrapped in gauze until it is used 
later to cover in the defect. The dissection is now completed 
usually with gauze, the tissues are loosened up underneath the 
pectoral muscles under the breast and toward the chest, and 
the remaining attachments of the muscles separated. After 
the pectoralis major muscle has been entirely separated from 
beneath, the breast is allowed to drop back into its normal 
position, the skin incision is completed and the breast and 
pectoral muscles are finally removed. 



342 Diseases of the Breast. 

The quadrilateral flap of skin and superficial fascia which 
originally formed the anterior covering of the axilla is now 
stretched out by tenaculum forceps and transferred inward to 
cover the defect of the chest wall created by the removal of the 
skin of the breast about the nipple. This flap, which is one of 
the distinctive features of the operation, will always contract 
after it has been loosened and will look as though it could be 
of but little service. It is spread out by means of the tenaculum 
forceps already mentioned, with probably another pair on 
either side. As the flap is drawn over on the chest it is fixed 
by attachment to the corresponding skin margin, as shown in 
Plates LXVI and LXVII. Another distinctive point consists 
in catching up, with the tenaculum, the margin of the lower por- 
tion of the pectoral fold, which represents the integument which 
formed the original floor of the axilla and which in thin subjects 
is often very marked. The tenaculum on this margin is placed 
at such a distance from the lowest point of the first vertical line 
that when drawn upward it will bring this skin point up to the 
beginning of the first incision beneath the clavicle. This man- 
euver brings the loose skin from the floor of the axilla close 
around the axillary vessels and does away entirely with the 
axilla as a cavity. These tenacula are usually clamped and 
mark the fixed points of coaptation. 

An approximation suture of silk- worm gut is now placed 
at these points to steady the subsequent suturing. The re- 
maining portion of the incision may be closed either with inter- 
rupted or continuous sutures. A puncture in the lowest re- 
cesses of the wound space behind furnishes opportunity for a 
drainage tube. 

The steps of this operation are shown in Plates LX to 
LXVIII inclusive. 

I have employed this procedure in a reasonable number of 
cases and consider that it meets most of the requirements ad- 
mirably. The chief defect with it, a most serious one as I 



PLATE LX. 




Outline of skin incision complete, showing formation of first flap. 
(Jabez N. Jackson.) 



PLATE LXL 



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Carcinoma. 361 

see it, is that the skin flap is taken from a region near to, if 
not actually where the growth is situated — in the greater num- 
ber of cases — the axillary hemisphere. It insures easy closure 
of the wound, but at the expense of retaining suspicious if not 
certainly infected skin. Within the past year I employed this 
incision to my great regret in two cases certainly, as both were 
reoperated for recurrences in the skin within six months after 
operation. In one of them the tumor was situated at the 
sternal end of the breast, which made the recurrence all the more 
unlooked for and disappointing. In other cases where the 
growths were situated inferiorly and jar away from the flap, I 
have not, as yet, encountered recurrences. 

Another defect is that the skin overlying the entire breast is 
not sacrificed. This can, however, be overcome by broadening 
the ellipse and extending its inner half well to or beyond the 
middle line of the sternum. This must be done to be safe for tu- 
mors in the sternal half of the gland. Moreover, such a modifica- 
tion would permit of a freer removal of the deep fascia, which 
has recently been insisted upon as a pathological necessity. 
This operation is ingenious, original, and can be quickly done, 
but if more skin were removed, it would still permit of primary 
union and be followed by better ultimate results. 

In a communication] recently received from Dr. Jack- 
son, he states that the illustrations of his operation do not 
exactly represent the technique which he now employs. He 
states that he ''sacrifices practically the entire skin of the breast, 
or at least all lying within a radius of three or four inches be- 
yond the furthest extension of the tumor mass." With this 
modification I should think more favorably of his procedure. 

Dawbarn, of New York, has suggested an ingenious operation 
to supply the defect caused by the removal of the pectoralis 
major muscle. He transplants a part of the deltoid, having 
its origin at the outer half of the clavicle, attaching it to the 
severed pectoralis major which is attached to the inner half of 



362 Diseases of the Breast. 

the bone. In a personal communication to me he describes 
his operation as follows (it has not yet been published): 
"After both pectoral muscles have been removed our patients 
have no other means than the action of the anterior fibers 
of the deltoid for the advancement of the arm nor for its ad- 
duction. When one considers the point of origin of this por- 
tion of the deltoid, it is at once obvious that if this part of the 
muscle sprang from the inner rather than the outer half of the 
clavicle its power to produce such motions would be greatly 
increased. Bearing this in mind, I have for several years past 
quite regularly adopted a plan of muscle anastomosis, viz., 
the detachment from its origin of an inch (more if thought 
necessary) of the anterior fibers of the deltoid, the muscle 
being split in a direction parallel to its long axis for a distance 
quite short but sufficient to permit the detached portion to be 
sutured to a stump, of corresponding size, of the adjacent pec- 
toralis major. This resource is of course contraindicated if 
the cancer extends to the vicinity of the muscles involved in 
such contemplated anastomosis; but this relatively seldom 
occurs. The stump of the great pectoral may be left an inch 
long (sometimes longer) in order to permit the more ready 
accomplishment of union of muscle to muscle. On the other 
hand the deltoid, as just stated, is dissected as far as it is to be 
so used from a level as close to the collar bone as possible. 
I have found three medium twenty-day tanned chromic catgut 
sutures to be quite sufficient ; and the entire little procedure 
adds only some five minutes to the length of work. As a rule 
it is easy to avoid injury to the cephalic vein — the preservation 
of which is at times so important — the deltoid slip being 
fashioned so as to cross obliquely in front of the vein. So far 
as I have been able to determine, the portion of the deltoid enter- 
ing into the anastomosis is not deprived of its innervation, nor 
does it undergo atrophy; though obviously, to avoid this, it 
should be split down for as brief a distance as good work will 



arcinoma, 



363 



permit. On the other hand it does secure what is intended, 
namely, facihtation of flexion and adduction of the humerus." 
While this device of Dr. Dawbarn is entirely original and 
another evidence of his surgical fertility, it is, I believe, wholly 
unnecessary and intended to correct a condition which I do not 




Fig. 38. — Primary incision in Tansini's operation. 

think exists. There is no trouble about patients who have had 
their pectoral muscles removed adducting the arm, or, indeed, 
doing anything else that they were able to do before such re- 
moval. I have already expressed my opinion fully enough on 
this subject. 

Of the plastic procedures practised by foreign surgeons, I 
shall describe that of Tansini, which is one of the best. 
This incision has been imitated bv other surgeons, but the 



364 Diseases of the Breast. 

principal feature of the operation, and its best, viz., bring- 
ing the flap from the back where the skin is presumably 
healthy, undoubtedly originated with Tansini. I have never 
employed it, because of the difficulty of its execution, the 
possibility of sloughing, even though rightly done, and the 
great probability of its occurrence if a false step is made. 




GZC. 
Fig. 39- — Second incision in Tansini's operation. 

In Tansini's operation, the broad oval incision must extend 
to the outermost point of the axilla (Fig. ^S) so that the narrowest 
portion of the entire wound, that is, the point of union of the 
two incisions, shall be there. Thus the autoplastic flap 
formed by the second incision (Fig. 39) will cover in the axillary 
space in such a manner that the upper extremity of the cica- 
trices will correspond to the anterior and posterior axillary 



Carcinoma 



365 



borders respectively, the center of the space being protected 
by healthy skin. The flap formed by the second -incision 
must be 6 or 7 cm. (about 2J inches) in breadth, and have 
its center corresponding to a point 3 cm. (ij- inches) from the 




Fig. 40. — Showing cicatrix in Tansini's operation. Front view. 

posterior axillary border, 5 cm. (2 inches) from the spine of the 
scapula, and 10 cm. (4 inches) from the angle of the scapula. 
Its anterior border is outlined by cutting from the termination 
of the first incision at the outermost point of the axilla down- 
ward and inward towards the midline of the back. This 
cut is then carried horizontallv and with a slioiht curve across 



366 



Diseases of the Breast. 



the back and upwards to a point opposite and 6 cm. (2f inches) 
internal to the point of starting, thus forming the posterior 
border. This flap is easily drawn forwards and made to 
cover the defect in skin caused by the removal of the breast, 




Fig. 41. — ShoT\-ing cicatrix in Tansini's operation. Side view. 

and, moreover, as already stated, supplies the axillary space 
with a covering of healthy skin. The dorsal wound is closed 
by a series of linear sutures. A small area at the lower ex- 
tremity often remains open. (Figs. 40 and 41.) 

As first practised by its originator this operation did not 
give invariably good results owing to frequent sloughing of the 



Carcinoma. 367 

flap, sometimes to the extent of one-third of its surface. A 
careful study of anatomical preparations, however, enabled 
him to overcome this disadvantage. It was found that certain 
important branches given off by the dorsalis scapulae (arteria 
scapularis circumflexa), itself a branch of the subscapular, 
are contained in the stem of the flap. This vessel passes 
between the teres major and teres minor muscles and one of its 
terminal branches supplies both latissimus dorsi and the skin 
over it. In addition to this branch, however, the latissimus 
dorsi receives branches directly from the subscapular. 

From the above considerations it will be seen that in order 
to preserve the vitality of the flap, it is necessary to include 
the latissimus dorsi and to insure a still better blood supply, 
a piece of the teres major may also be included. 

In dismissing plastic procedures in general, I wish to state 
positively that the prominence given them is out of deference 
to the opinion of many surgeons whose judgment I value, 
and also to meet a demand — with some a paramount one — 
of securing easy primary coaptation of the wound. That 
they do so frequently at the expense of an abiding result, I am 
now fully persuaded after a fair, and I think I may say con- 
scientious, employment of them for a period of ten years. 
They are inadequate, disappointing, and do not meet the 
pathological requirements necessary in dealing with an infil- 
trating and disseminated malignant process. The prime 
defect with all of them is that they subordinate a radical cure 
to the carrying out of a preconceived plan which will do very 
well in some cases where the lesion is favorably situated, but 
must fail in many, perhaps most instances where they are 
practised. I cannot doubt that he who employs them in 
many cases will find himself sooner or later, as I have been, the 
victim of chastened hopes, and definitely put them to the 
one side as alluring and convenient for the surgeon, but an 
enormous handicap to the patient. 



368 Diseases of the Breast. 

If cancerous growths were ahvays to be found in precisely 
the same situation in every case (instead of as they are indiffer- 
ently, some central, more peripheral, and about an equal 
number in each of the four quadrants of the mammary gland), 
then I could easily understand how a skin flap could be so 
fashioned as to meet every requirement, surgical and patho- 
logical. But with growths so widely variant as we find them to 
be in carcinomatous breasts, there is but one safe rule to follow, 
and that is to sacrifice every particle of skin superlying the entire 
mamma. Anything short of this is simply courting failure. 

Palliative Operations. — The more I see of palliative operations, 
the more I am impressed with their uselessness. I have about 
come to the conclusion, that any case so advanced as to forbid a 
reasonable hope of complete extirpation of the disease should be 
treated by non-operative measures. I have no hesitation in say- 
ing that the few patients upon whom I have performed 
palliative operations, hoping to relieve pain and prolong life, 
have been sadly disappointing to me. Pain is only relieved 
for a time, and it is my belief that the end is hastened rather 
than delayed by partial operations. I will not say that a foul 
ulcerating mass may not be removed for the purpose of giv- 
ing temporary comfort, but am distinctly of opinion that 
little encouragement should be given a patient thus affected 
either as to decided relief from pain or prolongation of life. 
I would much rather in such cases do a still more radical 
operation than ordinarily practised, even going so far, as I 
have done in one case, to remove a portion of the sternum and 
several ribs with a part of the parietal pleura, if there seems 
the least hope of getting beyond the apparent limits of the 
disease. In the case referred to, life was undoubtedly pro- 
longed by the heroic measures employed, and I was greatly 
surprised to see the woman come into my of&ce one day 
when I had supposed her dead for more than a year. She 
lived nearly three years after my last operation. 



Carcinoma. 369 

The recent statistics of the Johns Hopkins Hospital just 
pubHshed by Bloodgood, confirm me in the opinion that hfe 
is undoubtedly shortened by partial operation, as such patients 
five only 2.2 years if operated upon, whereas they live 3.2 
years without operation. Moreover, such operations un- 
doubtedly do the cause of surgery harm on account of the 
deterrent effect they have upon operable cases. Patients 
are sure to learn of them and do not understand that such 
operations were done as a dernier ressort and with little, if 
any, hope of permanent benefit accruing therefrom. 

Occasionally, but very seldom, in my judgment, will a case 
be encountered where Berger's operation must be considered. 
Within the past six months such a case presented itself to me, 
and the accompanying photographs show the condition of 
the patient prior to operation. Her plight was truly a pitiable 
one. She had been operated on by another surgeon, and there 
was prompt recurrence in spite of a very thorough oper- 
ation so far as I could judge from the history. Her arm was 
enormously swollen, it being more than double, in fact nearly 
thrice the size of the opposite limb. It was so heavy that the 
patient had to stay in bed on account of the great pain occa- 
sioned by the weight of the limb when she was up. Her 
suffering was so intense that I finally consented, after her 
urgent and repeated insistence, to remove the arm. The 
entire scapula and outer two-thirds of the clavicle were also 
removed, as well as all visibly affected soft parts. The patient 
made a good operative recovery, and was entirely relieved 
of pain for a time, moreover, she was able to walk about the 
hospital and to enjoy a degree of comfort which she had not 
known for months. The relief, however, was of brief dura- 
tion, as she died of internal metastasis five months after the 
operation. (Plates XL and XIJ.) 

I am most pessimistic as to the value of operations in cancer 

en cuirasse. Never have I seen good result from them, and 
24 



370 Diseases of the Breast. 

seldom, in my judgment, should operative measures be 
employed. 1 can easily understand how the lesions might 
be so discrete as to admit of removal by v^ide and free 
operation. But I repeat, such cases must be rare, as I have 
not seen one. 

Treatment of Inoperable Cases by Rontgen-rays, Etc. — It is not 
my purpose to go exhaustively into the subject of the value of the 
Rontgen-rays in malignant disease. This belongs to special mon- 
ographs on the subject. Briefly, I should say that all inoperable 
cases may be treated by the X-rays and that some will find 
more or less relief from pain and apparent benefit so far as 
reduction in size of the tumor is concerned. A few cases are 
undoubtedly made worse by the treatment, the growth seem- 
ingly being stimulated to an unwonted degree rather than 
repressed. No one can tell what is to be the result in any 
given case and the use of the rays must, in the present state 
of our knowledge, be empirical. 

I formerly subjected most of my patients after operation to a 
certain number of treatments by the X-rays and then believed 
such a course warranted. But the fact that I have seen the 
disease stimulated and made to pursue a more rapid course 
has made me sceptical, and I now limit the use of the rays 
to inoperable cases, or to those where there is a doubt as to 
the complete eradication of the disease by operation. 

I have seen the best results follow the rays in superficial 
squamous epithehomata and lupus. I have also witnessed 
remarkable results occasionally in the treatment of inoperable 
sarcomata, but I fail to recall a single case where the X-rays 
exerted more than a temporary benefit in a case of cancer 
of the breast. We may find in time that the variety of the 
growth will influence the result perceptibly. They apparently 
do little good in scirrhus. 

As already indicated, the X-rays are entitled to a greater 
degree of confidence in the treatment of inoperable sarco- 



Carcinoma. 371 

mata than we have a right to expect when deahng with 
carcinomata. I have not used this treatment in sarcoma of 
the breast, but have so often seen gratifying results, occasion- 
ally astounding ones, from the use of the rays in sarcomata 
located elsewhere that I should be inclined to advise this 
treatment in any case where operative measures were clearly 
out of place. W. B. Coley has cured one such case by the 
use of his toxins. I have had a reasonably large experience 
in the treatment of sarcomata elsewhere by Coley 's method, 
having used it in more than one hundred cases. In many 
there was prompt and distinct betterment, causing me to be- 
heve for a time that a cure might be effected. In only one case, 
however, have I seen such a result. An extensive sarcoma 
of the pharynx was entirely cured by the use of toxins and 
has remained well for more than ten years. When the treat- 
ment was begun, at my suggestion, by a former colleague. Dr. 
M. F. Coomes, of Louisville, Ky., it was my belief that the 
patient would not live six months. 

I am also convinced that a patient with sarcoma of the parotid 
who had been twice operated upon by a New York surgeon, 
and who declined a third operation, fearing paralysis of the 
facial nerve, which she was told would almost certainly ensue, 
was so much benefited by the toxin treatment that she might 
have been cured had she not been compelled to leave here and 
discontinue the treatment. 

I consider the treatment by toxins of sufficient value to be 
insisted upon in all clearly inoperable cases of sarcoma and 
am, moreover, inclined to give a few injections as a prophylactic 
against recurrence after operation, even in favorable cases. 

I have seen no good whatsoever come from the toxin treat- 
ment in cancer, though I formerly used it in many cases. 



FACET'S DISEASE OF THE NIFFLE. 

This disease, which was first described by Sir James Paget, 
in 1874, and which appears in the nipple and areola as an 
eczematous inflammation, has been the subject of much 
discussion by surgeons, dermatologists and pathologists. 
Moreover it is one which has always been fraught with interest 
because of its relation to cancer, and at the present time 
particularly it has attracted renewed attention by reason of 
the important pathological studies which have been made of 
it by several investigators. 

It may not be amiss briefly to review the history of this 
disease and mention the more important theories which have 
been advanced relative to its nature. 

Paget himself, basing his opinion on the study of fifteen 
cases, described the affection as a disease of the mammary 
areola preceding cancer of the mammary gland. He considered 
the changes in the skin to be the expression of chronic irrita- 
tion, a kind of eczema, and believed that this supplied a soil 
favorable for the development of carcinoma. In all of his 
cases cancer of the breast developed subsequently, and it was 
this circum.stance which led him to call attention to the disease. 
He states that "for an explanation of these cases it may be 
suggested that a superficial disease induces in the structures 
beneath it, in the course of many months, such a degeneracy 
as makes them apt to become the seats of cancer; and that 
this is chiefly likely to be observed in the cases of those struc- 
tures which appear to be, naturally, most liable to cancer, as 
the mammary gland, the tongue and the lower lip." 

Paget's opinion was accepted for a considerable period of 
time. 

372 



Paget's Disease of the Nipple. 373 

In 1 88 1, however, Thin pubhshed his paper on ^^Mahgnant 
Papillary Dermatitis of the Breast," which he stated to be 
the same disease previously described by Paget. He differed 
from the latter, however, in believing it to be carcinomatous 
from the very beginning, and that the original location of the 
morbid process is within the galactophorous ducts. He declared 
that the involvement of the epidermis was secondary. Thin's 
theory was also accepted by Duhring, Raymond Johnson, 
and many others and it is the one which I myself accepted 
without hesitation as announced in several previous com- 
munications on the subject. 

In 1889 Darier enunciated his parasitic theory, in which 
he maintained that the disease was due to infection by psoro- 
sperms. A year later Wickham published a paper in which 
he strongly supported Darier's theory. Darier himself, how- 
ever, later changed his views, but notwithstanding this fact 
his original theory has continued to be cited from time to time. 

Kaposi expressed himself as being of the opinion that the 
disease is not a morbid entity, but that it is rather an obstinate 
form of eczema, which though it may develop into cancer, is 
yet susceptible of cure. Unna, per contra, considers it to be 
a disease sui generis differing from both carcinoma and eczema, 
although he admits that it may supply a basis for the de- 
velopment of carcinoma. Recent careful histological studies 
have served to increase our knowledge of the true nature 
of the disease. They will be discussed when we come to 
consider its pathology. 

In regard to the etiology of this disease little is known. 
The vast majority of cases have occurred in women, although 
some have occurred in men. Thus, for example, Crocker 
observed a case in which the penis and scrotum were affected, 
and Stelwagon has also reported one in which the disease was 
confined to the scrotum. 

In this connection it is interestine: to note that instances in 



374 Diseases of the Breast. 

which parts other than the breast were attacked have been 
observed in the female. Holzknecht mentions one in which 
the primary location was probably the axilla, and Shield saw 
one which affected the abdominal wall. 

As concerns age, the majority of cases occur between the 
fortieth and sixtieth years, although some have been observed 
in women as young as twenty-eight and several have been 
reported in those over seventy. 

The influence of heredity is unknown. 

The influence of pregnancy and child-bearing is very in- 
definite, if indeed they have any effect. Cases have been 
reported in women who have never been pregnant, as well 
as in those who have borne and suckled children. It is natural 
to suppose that the irritation of the nipple caused by nursing 
might predispose to the development of the disease, but, as 
already stated, nothing definite is known in regard to the 
matter. 

Pathological Anatomy. — If a section of the diseased tissue 
from a case of Paget's disease be examined under the micro- 
scope, a collection of large transparent cells will be observed 
in the deep layers of the epidermis. These cells differ from 
those of the rete Malpighii in that their protoplasm is much 
clearer, and they are also larger. They have several nuclei 
which stain readily and are rich in chromatin. The protoplasm 
is often vacuolated. In some instances the cells are not com- 
pactly arranged, spaces of considerable size intervening. 
Schambacher, however, found them arranged in strands which 
were surrounded by an envelope of connective tissue. The 
epidermis is thickened, the cells small and atrophied. Recent 
careful; observations tend to show that there are no transi- 
tional cells between the large, clear so-called Paget cells and 
natural epithelial cells (Jacobaeus, Schambacher). Some 
investigators have thought that the former are degenerated 
epithelial cells, but more careful observations have shown 



Paget's Disease of the Nipple. 375 

that such is not the case. In one of the preparations examined 
by Jacobaeus the Paget cells were found to be continuous with 
the cells of the glandular carcinoma, and the same condition 
was observed by Schambacher. Furthermore, they were 
found to extend to the superficial layer of the skin in areas 
where the disease was most advanced. Thus it is seen that 
there is a direct communication between the morbid process 
in the skin and that affecting the gland, and it is surely logical 
to infer that the disease is carcinomatous from the very begin- 
ning. No convincing evidence has been adduced to show 
that a secondary carcinomatous degeneration takes place, 
and it was mere presumption which led to the enunciation of 
such a view. As already stated, I have always maintained 
that true Paget's disease was nothing more or less than car- 
cinoma, and I am still inclined to believe with Thin, Duhr- 
ing and others that the disease begins in the galactophorous 
ducts and later invades the nipple and areola by direct ex- 
tension to the surface. 

A contribution to the study of Paget's disease made by 
Schambacher in the Deutscher Zeitscrift fiir Chirurgie, No- 
vember, 1905, is of such importance that attention must be 
given to the conclusions drawn from the study of this case. 
Allusion has already been made to the arrangement of the Paget 
cells in this specimen. Taking into consideration the clinical 
course of the disease in conjunction with the pathological find- 
ings, the author comes to the conclusion that the disease was 
originally an intraepidermoid carcinoma which invaded both 
milk-ducts and skin. He considers it analogous to the form of 
cutaneous carcinoma recently described by Borman. The 
cutaneous lesions in addition to those produced by the malig- 
nant process itself he found to be due to inflammatory infiltra- 
tion, which, indeed, predominates in the skin, and it is this 
condition which gives the disease its eczematous character. 
Schambacher based his views, so far as the clinical aspect of 



376 Diseases of the Breast. 

the malady is concerned, upon the following circumstances, 
which I deem it appropriate to mention in this place. The 
disease began with the formation of a crust upon the nipple 
which finally fell off and left a reddened inflamed surface, the 
redness extended to the areola very slowly and did not invade 
the skin of the breast for five years, no evidence of disease in 
the mammary gland itself was detected until four and one-half 
years after the lesion on the nipple was first noticed. More- 
over, both gross and microscopic examination'showed the nipple 
to be the part most severely affected. Indeed, the structure 
was almost completely destroyed. 

These considerations are certainly worthy of careful atten- 
tion and should afford a basis for still further observations. 

Symptoms. — Paget's disease apparently begins as an eczem- 
atous inflammation of the nipple which extends concentrically 
to the areola. Very often the first thing which attracts atten- 
tion is the formation of one or more small grayish scales on the 
nipple, together with slight redness of the contiguous parts of 
this structure. This condition may or may not be accompanied 
by slight itching or burning. This stage of the disease may con- 
tinue unchanged for many months. A notable thing about it, 
and one which is important from the standpoint of diagnosis, 
is that the lesions are entirely uninfluenced by the ordinary 
remedies to which mild forms of eczema not uncommonly yield. 
As the morbid process advances the areola becomes involved. 
Fissures develop and raw, eroded spots make their appearance. 
At this period the lesions may assume a moist character, or 
they may continue to be dry, much like psoriasis. (See Plate 
XLIII and Fig. 42.) 

In some cases, the diseased parts are moist almost from the 
very beginning of the disease. 

Both of these forms were recognized by Paget. His descrip- 
tion of well-developed cases cannot be improved, so I will 
quote it verbatim. He states that in the majority of cases '* it 



Paget's Disease of the Nipple. 



377 



had the appearance of a florid, intensely red, raw surface, very 
finely granular, as if nearly the whole surface of the epidermis 
were removed ; like the surface of a very diffuse acute eczema, or 
like that of an acute balanitis. From such a surface on the 
whole or greater part of the nipple and areola, there was always 




Fig. 42. — Paget's disease of the nippk 



copious, clear, yellowish, viscid exudation. The sensations 
were commonly tingling, itching and burning, but the malady 
was never attended by disturbances of the general health. In 
some of the cases the eruption has presented the characters 
of an ordinary chronic eczema, with minute vesications, suc- 
ceeded by soft, moist, yellowish scabs or scales, and constant 
viscid exudation. In some it has been hke psoriasis, dry, with 
a few white scales, slowly desquamating, and in both these 



37^ Diseases of the Breast. 

forms I have seen the eruption spreading far beyond the areola 
in widening circles, or, with scattered blotches of redness, 
covering nearly the whole breast." 

This extensive involvement of the skin has been occasionally 
seen from time to time by later observers. In a remarkable case 
reported by Neisser the morbid process invaded the whole side 
of the body, passing from the breast to the sternum, over the 
shoulder onto the back, and then extending anteriorly to the 
abdominal wall. 

There is usually a distinct line of demarcation between the 
healthy and diseased parts. Healing may take place in cer- 
tain portions of the diseased area, although this occurrence is 
by no means constant. In the dry cases there is a peculiar 
parchment-like appearance and feeling of the diseased area. 

Retraction of the nipple occurs as the disease progresses, 
and in far advanced cases the nipple may be nearly or entirely 
destroyed, an excavated ulcer, or perhaps merely shght depres- 
sion, taking its place. 

In such cases more or less involvement of the axillar}^ glands 
will not uncommonly be detected. The integument of the 
axilla may also be somewhat reddened and edematous. Some- 
times instead of showing ulceration this flattened or deepened 
surface may be covered with scales. 

In course of time the cancerous nature of the disease invari- 
ably manifests itself in the tissues of the mammary gland. 
Paget states that the disease of the nipple was followed by 
cancer of the breast in from one to two years. Further ob- 
servation, however, has proved that several years may elapse 
before gross changes in the mamma itself can be detected. 

The most important thing in Paget' s original paper, as 
he himself stated, was the emphasis placed upon the invariable 
sequence of mammary cancer in this disease. His observations 
are entirely in accord with our present belief that the malady 
is cancerous from the very beginning. It is pertinent to this 



Paget's Disease of the Nipple. 379 

subject to state that a vast number of cases reported as Paget's 
disease were in reahty hot such, but were of such slow evo- 
lution as to lead one into the belief that they did not par- 
take of the nature of cancer. Thus, no doubt, may be ex- 
plained the small percentage of cases studied by Williams in 
which cancer developed. This slow evolution which character- 
izes some cases is the circumstance above all others which gives 
some plausibility to the theory of intraepidermoid origin of the 
cancerous process, to which reference has already been made. 

An important circumstance in the natural history of the 
disease is that only one nipple is affected at first, simultaneous 
eruption of the morbid process in both never having been ob- 
served. Cases have been recorded, however, in which the 
second nipple became involved at a later period, or after the 
other had been removed. 

In contrast to what has already been stated concerning the 
protracted course of some cases, it may be said that there are 
others of very rapid evolution in which well-developed signs of 
glandular carcinoma manifest themselves within a few months 
after the primary lesions of the nipple and areola appear. 
Then there are other cases which remain stationary for a long 
period only to advance rapidly to glandular involvement. In 
some of these cases traumatism has been blamed for the sud- 
den progress of the disease, whereas in others no determinable 
causes for the newly assumed and unwonted activity were 
present. 

In comparison with other forms of cutaneous carcinoma 
Paget's disease may be considered comparatively benign. 
Naturally when the carcinomatous process has extended to the 
glandular structures of the breast the prognosis is less favorable. 

Diagnosis should present no difficulties, particularly in well- 
marked cases which have existed for some time. Beginning 
cases might be mistaken for simple excoriation or eczema of 
the nipple, but the failure of the lesions to yield to the ordinary 



380 Diseases of the Breast. 

remedies — boric acid, salicylic acid, zinc oxide, etc. — should at 
once arouse suspicion as to the true nature of the disease. In- 
deed the occurrence of lesions such as have been described under 
symptomatology should immediately lead the physician to 
suspect Paget's disease. 

Treatment. — The treatment of Paget's disease is entirely 
surgical and consists, in my opinion at least, in early amputa- 
tion of the breast and exploration of the axilla in every case. 
If infected it should be thoroughly cleaned out. I cannot 
approve of partial resection, or, indeed, anything less radical 
than that which is believed to be necessary at the present time 
to successfully contend with a malignant process in glandular 
structures richly endowed with lymphatic vessels. Every theory 
worthy of the least acceptance admits the malignant nature of 
the affection and its ultimate tendency to involve the breast. 

The only difference between pathologists is where it begins. 
Clinically this is negligible, as the skin is very early involved 
in cancer of the breast, and it is reasonable to assume that 
when the overlying nipple and areola are involved in a carcinom- 
atous process, the time soon comes when the condition of the 
breast must be questioned on account of the free communication 
between said structures. It is then carcinoma of either the 
galactophorous ducts or skin primarily with certain involvement 
of both, and the breast as well, secondarily. Therefore, the 
future safety of the patient will be menaced by temporizing 
agents in the shape of lotions, unguents, caustics and electricity, 
and scarcely less so by incomplete operations. 



INDEX 



Abnormal involution, 70 

See also under General Cystic 
Disease, 66 
Abscess, acute, 30 
treatment of, ^t, 
chronic, 41 

treatment of, 42 
retromammary, 30 
treatment of, 34 
Acute cancer, 226 

mastitis, 29 
Actinomycosis, 67, 
Adenocarcinoma, 186 

diagnosis from adenoma, 252 
Adenofibroma, see under Peridudal 
Fibroma, 106; also under Fibro- 
epithelial Tumors, 103 
Adenoma, simple, 121 

See also under Fibro-cysf adenoma, 
112; Papillary Cystadenoma, 114; 
and Fibroepithelial Tumors, 103 
Adenosarcoma, 163 
Alveoli, during lactation, 22 
Amazia, 14 

Anesthesia, induction of, 286 
Anesthetic, choice of, 286 
Angioma, 155 
etiology of, 155 
morbid anatomy of, 155 
symptoms of, 159 
treatment of, 159 
Areola, structure of, 2 
Arteries of the breast, S 

of the nipple, 8 
Athelia, 14 

Amputation of the breast, for benign 
tumors, 126 
for carcinoma, 266 
for sarcoma, 171 
for suppurative disease, 35 
for tuberculosis, 54 
Anatomy, 1-16 



Anatomy, descriptive, 1-5 
blood supply, 5 
nerve supply, 13 
lymphatics, 10 
structural abnormalities, 14 
Atrophic carcinoma, 196 
Axilla, dissection in operation for can- 
cer, 275, 288 
Axillary glands, removal in operation 
for carcinoma, 275, 288 
time of involvement in carcinoma, 

- 223 
vein, injuries of, 392 
resection of, 392 

Cancer, 173 

See under Carcinoma, 173 
Cancer en cuirasse, 195 

symptoms of, 230 
Carcinoma, 173 

age incidence of, 176 
atrophic, 196 

course of, 225 
author's operation for, 287 
axillary glands in, 202 

time of involvement, 223 

removal of, 275 
bilateral, 183 
bones in, 214 
brain in, 216 
cachexia in, 224 
concealment of, 218 
curability of, 254 

See also under Prognosis, 253 
constitutional disturbances in, 224 
diagnosis of, 235 

from abnormal involution, 249 

from benign tumors, 249, 252 

from chronic mastitis, 249 

from, cysts, 251 

from sarcoma, 251 

from syphilis, 250 



38: 



382 



Index. 



Carcinoma, diagnosis of, from tuber- 
culosis, 250 
dissemination of, 200 

by permeation, 206 

through the blood, 211 

through the lymphatics, 201 
duration of life in, 253 

See also under Prognosis, 253 
edema of arm in, 224 
en cuirasse, 196, 230 
etiology of, 173 

age, 176 

heredity, 180 

inflammation, 182 

injury, 182 

race, 179 

sex, 175 

social condition, 181 
evolution of, 217, 219 
examination of patient in, 241 
fixation of breast in, 220 
germ theory of, 1 73 
history of operation for, 266 
inguinal glands in, 206 
inoperable, treatment of, 262, 263, 

264, 370 
in negroes, 179 
in young women, 177 
Jackson's operation for, 326 
late recurrence of, 255 
lungs in, 214 

mediastinal glands in, 205 
metastases in, 200, 214 
microscopic test for, 247 
mucoid, 199 

of the male breast, 175, 178, 182 
operations for, 266 287, 322, 2)'^^^, 
326, 361, 363 

mortality of, 236 

requisites of, 280 

technique of, 282 
ovaries in, 217 
pain in, 217, 245 
palliative operations for, 368 
plastic operations for, 322 
post-operative treatment, 319 
pathology of, 186 

See also under Varieties of Carci- 
noma, 186; Dissemination, 200 
pectoral fascia in, 205 
pleura in, 214 
pleural effusion in, 224 
prognosis of, 253 



Carcinoma, relative importance of 
several steps of operation, 280 
retraction of the nipple in, 220 
simplex, 192 
spinal cord in, 205 

spontaneous fracture in, 215, 218, 224 
sternal symptom in, 245 
supraclavicular glands in, 202 
symptoms of, 217 
constitutional, 224 
local, 219 
Tansini's operation for, 363 
technique of operation for, 282 
treatment of, 259 
by caustics, 262 
by oophorectomy, 263 
by operation, 266 
by trypsin, 263 
by the X-rays, 261 
ulceration in, 223, 225 
uterus in, 217 
varieties of, 186 
acute, 226 

adenocarcinoma, 186 
carcinoma simplex, 192 
carcinomatous cyst, 199 
gelatinous, 199 
medullary, 192 
scirrhus, 195 
Warren's operation for, 323 
withering, 196 

course of, 225 
X-rays for, 262, 370 
Carcinomatous cyst, 199 
Cartilaginous tumors, 150 
Caustics, for carcinoma,. 262 
Chondroma, see under Encondroma, 150 
Chondro-osteoma, 150 
Chondro-sarcoma, 150, 151 
Chronic abscess, 41 

mastitis, 35 
Circle of Haller, 9 
Cystic adenoma, see under Fibro- 

cystadenoma, 112 
Cystic disease, general, 66 
treatment of, 73 
with associated carnnoma, 73 
See also under Chronic Mastitis, 

35 
Cystic sarcoma, 163 
Cysts, 64 

carcinomatous. 199 

dermoid, 81 



Index. 



3&3 



Cysts, echinococcus, 79 

hydatid, 79 

lymphatic, 65 

milk, 74 

retention, 64 

sebaceous, 82 

varieties of, 64 
Colostrum, definition of, t8 
Congestion, 27 

treatment of. 28 

Dawbarn's method of transplanting 

pectoralis major muscle, 361 
Drainage after operation for carcinoma, 

397 
Dermoid cyst, 81 
Diffuse hypertrophy, 83 

etiology of, 8^ 

pathology of, 84 

symptoms of, 84 

treatment of, 86 

Echinococcus cyst, 79 , 
Enchondroma, 150 

etiology of, 151 

treatment of, 152 
Endothelioma, 160 
Engorgement, 27 

treatment of, 28 
Evolution of breast, see under Puberty, 
Pregnancy and Lactation, 17, 18 

Fascia, removal of in operation for 

carcinoma, 277 
Fascial lymphatic plexus, ir 
Fibroadenoma, see under Periductal 

Fibroma, 106 ; also under Fi- 

broepithelial Tumors, 103 
Fibro-cystadenoma, 112 
Fibroma, see under Periductal Fibroma, 

106 

Galactocele, 74 

diagnosis of, 79 

etiology of, 75 

frequency of, 74 

pathology of, 78 

symptoms of, 78 

treatment of, 79 
Gelatinous carcinoma, 199 
General cystic disease, 66 

Hydatid cyst, 79 



Hypertrophy, diffuse, 83 
etiology of, 83 
pathology of, 84 
symptoms of, 84 
treatment of, 86 

Inflammatory diseases, 27, 42 
Intracanalicular fibroma, 11 1 
Involution, 25 

abnormal, 70 

changes in breast during, 25 

definition of, 25 

Jackson's operation for carcinoma, 326 
Keloid, 88 

Lactation, persistent, in new-born, 17 

structural changes in breast during, 
22 

establishment of, 21 

mechanism of, 21 
Lipoma, 147 

etiology of, 147 

intraglandular, 148 

retromammary, 148 

subcutaneous, 147 

treatment of, 149 

varieties of, 147 
Lymphatics, cutaneous, 10 

deep, 10 
Lymphatic cyst, 65 

plexus, fascial, 11 

Maladie noueuse, 69 

See also under General Cystic 
Disease, 66 
Male breast, anatomy of, 15 

carcinoma of, 175, 178, 182 
Mastitis, acute, 29 

diagnosis of, 31 

etiology of, 28, 29 

parenchymatous, 30 

prophylaxis of, 32 

superficial, 29 

symptoms of, 31 

treatment of, ^t, 

varieties of, 29 
chronic, 35 

definition of, 35 

etiolog}' of, 35 

pathology of, 39 

symptoms of, 40 



384 



Index. 



Mastitis, dironic, treatment of, 41 
Medullary carcinoma, 192 
Mucoid carcinoma, 199 
Myxoma, 153 
Myxosarcoma, 166 

Nerves, 13 

Nipple, absence of, 14 

blood supply of, 8 

Paget' s disease of, 372 

structure of, 2 

Oophorectomy, for inoperable carci- 
noma, 264 
Operation for benign tumors, 126 
for carcinoma, author's method, 287 
Jackson's method, 326 
Tansini's method, 363 
Warren's method, 323 
history of, 266 
relative importance of several steps, 

280 
technique of, 282 
treatment after, 319 

Paget's disease of the nipple, 372 

diagnosis of, 379 

etiology of, 373 

history of, 372 

morbid anatomy of, 374 

symptoms of, 376 

treatment of, 380 
Palhative operations for carcinoma, 

368 
Papillary cystadenoma, 114 

age incidence of, 118 

diagnosis of, 118 

morbid anatomy of, 114 

prognosis of, 122 

symptoms of, 118 

synonyms of, 114 

treatment, of, 125 
Para -mammary fat, removal of in oper- 
ation for carcinoma, 278 
Pectoral muscles, importance of re- 
moving in operation for carci- 
noma, 269, 276 
Pericanahcular fibroma, III 
Periductal fibroma, 106 

morbid anatomy of, no 

symptoms of, 109 

prognosis of, 122 

treatment of, 125 



See also under the various members 
of the group 
Periductal sarcoma, 163, 166 
Permeation, theory of, 206 
Physiology, 16 

Plastic operations for carcinoma, 322 
value of, 367 
resection for benign tumors, 126 
Polycystoma, see under Fibro-cystade- 

noma, 112 
Polymastia, 14 
Polytheha, 14 

Pregnancy, as an etiological factor in 
carcinoma, 181 
changes in breast during, 18 
Puberty, changes in breast during, 1 7 

Retention cyst, 64 

Retrograde lymphatic embolism, 206 

Retromammary abscess, 30 

Sarcoma, 161 

age incidence of, 164 

diagnosis of, 169 

etiology of, 162 

pathology of, 163 

prognosis of, 171 

relative frequency of, 161 

symptoms of, 166 

treatment of, 171 

varieties of, 162, 165 
Scirrhus carcinoma, 195 
Sebaceous cyst, 82 
Simple carcinoma, 192 
Skin grafting, value of, 274 

incision in operation for carcinoma, 
272 
Stiles's nitric acid test, 278 
Supraclavicular glands, removal of, in 

carcinoma, 270 
Syphilis, 57 

diagnosis of, 59, 61 

etiology of, 57, 58, 62 

frequency of, 57 

initial lesion, varieties of, 59 

secondary manifestations of, 60 

spirocheta pallida in, 6t 

tertiary manifestations of, 60 

treatment of, 62 

Tansini's operation for carcinoma, 363 
Transplantation of pectoralis major 
muscle, 361 



Index. 



385 



Trypsin, for carcinoma, 263 
Tubercles of Montgomery, 2 
Tuberculosis, 43 

associated with carcinoma, 48 

diagnosis of, 52 

etiology of, 45 

pathology of, macroscopic, 46 

microscopic, 47 
prognosis of, 53 
relative frequency of, 43 
symptoms of, 51 
treatment of, 54 
by operation, 54 
by bacterial vaccines, 55 
by iodoform injections, 55 
by the induction of passive hyper- 
emia, 56 
varieties of, 44, 46 
Tumors, 91 

benign, characteristics of, 95 
age incidence of, 100 
classification of, loi 
mammary, relative frequency of, 99 



Tumors, cartilaginous, 150 
classification of, 94 
definition of, 93 
epithelial, 173 
fatty, 147 
fibroepithelia], definition of, 103 

etiology of, 105 

general considerations, 103 

prognosis of, 122 

treatment of, 125 
general considerations, 91 
malignant, characteristics of, 96 

mammary, classification of, 102 
theories of, origin, 91 

See also under Adenoma, 121; 
Carcinoma, 173; Sarcoma, 161 

Veins of the breast, 8 

Warren's operation for carcinoma, 323 
Withering carcinoma, 196 
course of, 225 

X-rays, for carcinoma, 262, 370 



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